Method of treating cancer by administering an anti-LGR5 monoclonal antibody

ABSTRACT

The present invention relates generally to the field of cancer biology. Some embodiments of the methods and compositions provided herein relate to administration of humanized antibodies or antigen-binding fragments thereof that specifically bind to LRG5 to treat certain cancers.

RELATED APPLICATIONS

This application is the U.S. National Phase of PCT/AU2017/050250 filedMar. 21, 2017 which was published in English as WO 2017/161414 on Sep.28, 2017 which claims the benefit of U.S. Provisional Application No.62/311,631 entitled “ADMINISTRATION OF AN ANTI-LGR5 MONOCLONAL ANTIBODY”filed Mar. 22, 2016 the contents of which are expressly incorporatedherein by reference in their entireties.

FIELD OF THE INVENTION

The present invention relates generally to the field of cancer biology.Some embodiments of the methods and compositions provided herein relateto administration of humanized antibodies or antigen-binding fragmentsthereof that specifically bind to leucine-rich repeat-containingG-protein coupled receptor 5 (LGR5) to treat certain cancers.

REFERENCE TO SEQUENCE LISTING

The present application is being filed along with a Sequence Listing inelectronic format. The Sequence Listing is provided as a file entitledBIONO14NPSEQLISTING, created Sep. 17, 2018 which is approximately 40 Kbin size. The information in the electronic format of the SequenceListing is incorporated herein by reference in its entirety.

BACKGROUND OF THE INVENTION

Leucine-rich repeat containing G-protein-coupled receptor 5 (LGR5), alsoknown as GPR49/HG38/FEX, belongs to the leucine-rich repeat containingG-protein-coupled receptor (LGR)/G-Protein-coupled Receptor (GPR)protein family of receptor proteins that are structurally similar toglycoprotein hormone receptors. LGRs are divided into three subgroups:(1) glycoprotein hormone receptors including thyroid-stimulating hormone(TSH) receptor, follicle-stimulating hormone (FSH) receptor, andluteinizing hormone (LH) receptor; (2) relaxin receptors LGR7 and LGR8;and (3) LRG4, LGR5, and LGR6. LGR5 is expressed in several tissuesincluding the intestine, skeletal muscle, placenta, brain, and spinalcord.

SUMMARY OF THE INVENTION

Embodiments of the methods and compositions provided herein include amethod of treating a human subject having a metastatic colorectal cancercomprising administering an effective amount of a humanized monoclonalantibody that specifically binds leucine-rich repeat-containingG-protein coupled receptor 5 (LGR5) to the subject in need thereof,wherein: the monoclonal antibody comprises a heavy chain comprising SEQID NO:13 and a light chain comprising SEQ ID NO:14; the monoclonalantibody is administered weekly for at least 4 weeks; the monoclonalantibody is administered intravenously; and the dosage of the monoclonalantibody is between about 2.5 mg/kg to about 15 mg/kg.

In some embodiments, the monoclonal antibody is administered incombination with folinic acid, fluorouracil, and irinotecan. In someembodiments, an initial dose of the monoclonal antibody is administeredprior to administration of the folinic acid, fluorouracil, andirinotecan. In some embodiments, an initial dose of the irinotecan isabout 180 mg/m2 administered over about 90 minutes; an initial dose ofthe folinic acid is about 400 mg/m2 administered over about 120 minutesand concurrently with the initial dose of the irinotecan; an initialdose of the fluorouracil is about 400 mg/m2 administered afteradministration of the initial dose of the folinic acid; and the folinicacid, fluorouracil, and irinotecan are administered every 14 days.

Embodiments of the methods and compositions provided herein include amethod of treating a subject having a cancer comprising administering aneffective amount of a humanized monoclonal antibody or anantigen-binding fragment thereof that specifically binds leucine-richrepeat-containing G-protein coupled receptor 5 (LGR5) to the subject inneed thereof, wherein: the monoclonal antibody comprises a heavy chaincomprising SEQ ID NO:13 and a light chain comprising SEQ ID NO:14; themonoclonal antibody is administered weekly for at least 4 weeks; themonoclonal antibody is administered intravenously; and the dosage of themonoclonal antibody is between about 2.5 mg/kg to about 15 mg/kg.

In some embodiments, the monoclonal antibody is administered incombination with a chemotherapeutic agent. In some embodiments, thechemotherapeutic agent is selected from the group consisting of folinicacid, fluorouracil, irinotecan, gemcitabine and nanoparticlealbumin-bound paclitaxel (ABRAXANE).

In some embodiments, an initial dose of the monoclonal antibody isadministered prior to administration of a chemotherapeutic agent.

In some embodiments, the monoclonal antibody is administered incombination folinic acid, fluorouracil, and irinotecan. In someembodiments, an initial dose of the monoclonal antibody is administeredprior to administration of folinic acid, fluorouracil, and irinotecan.

In some embodiments, an initial dose of the irinotecan is about 180mg/m2 administered over about 90 minutes. In some embodiments, aninitial dose of the folinic acid is about 400 mg/m2 administered overabout 120 minutes and concurrently with the initial dose of theirinotecan. In some embodiments, an initial dose of the fluorouracil isabout 400 mg/m2 administered after administration of the initial dose ofthe folinic acid. In some embodiments, the folinic acid, fluorouracil,and irinotecan are administered every 14 days.

In some embodiments, the monoclonal antibody is administered incombination with an additional therapeutic agent selected from the groupconsisting of bevacizumab, aflibercept, cetuximab, and panitumumab.

In some embodiments, the cancer comprises a solid tumor. In someembodiments, the cancer is selected from the group consisting of coloncancer, colorectal cancer, pancreatic cancer, breast cancer, and lungcancer. In some embodiments, the cancer is selected from the groupconsisting of colon cancer comprising an APC mutation, colon cancercomprising an KRAS mutation, metastatic colorectal cancer, metastaticpancreatic cancer, triple-negative breast cancer, and small cell lungcancer. In some embodiments, the cancer is a metastatic colorectalcancer.

In some embodiments, the subject has a characteristic selected from thegroup consisting of: failed at least 1 line of prior chemotherapy formetastatic disease prior to administration of the monoclonal antibody;has no known brain metastases; has a life expectancy of 12 weeks ormore; has an absolute neutrophil count greater than about 1500 cells/mLwithout growth factor support in the 14 days prior to administration ofthe monoclonal antibody; has a platelet count greater than 100,000platelets/mL without transfusions in the 14 days prior to administrationof the monoclonal antibody; has a hemoglobin greater than or equal to9.0 g/dL; and has serum albumin greater than or equal to 3 g/dL.

In some embodiments, the subject is mammalian, for example, human.

Embodiments of the methods and compositions provided herein include acontainer comprising a pharmaceutical composition comprising a dose of ahumanized monoclonal antibody that specifically binds leucine-richrepeat-containing G-protein coupled receptor 5 (LGR5), and a suitablepharmaceutical carrier, wherein the dose of the monoclonal antibody isbetween about 2.5 mg/kg to about 15 mg/kg. In some embodiments, thepharmaceutical composition is suitable for intravenous administration.

Embodiments of the methods and compositions provided herein include ahumanized monoclonal antibody that specifically binds leucine-richrepeat-containing G-protein coupled receptor 5 (LGR5) for use intreating a metastatic colorectal cancer wherein: the monoclonal antibodycomprises a heavy chain comprising SEQ ID NO:13 and a light chaincomprising SEQ ID NO:14; the monoclonal antibody is administered weeklyfor at least 4 weeks; the monoclonal antibody is administeredintravenously; and the dosage of the monoclonal antibody is betweenabout 2.5 mg/kg to about 15 mg/kg. In some embodiments, the monoclonalantibody is administered in combination with folinic acid, fluorouracil,and irinotecan. In some embodiments, an initial dose of the monoclonalantibody is administered prior to administration of the folinic acid,fluorouracil, and irinotecan. In some embodiments, an initial dose ofthe irinotecan is about 180 mg/m2 administered over about 90 minutes; aninitial dose of the folinic acid is about 400 mg/m2 administered overabout 120 minutes and concurrently with the initial dose of theirinotecan; an initial dose of the fluorouracil is about 400 mg/m2administered after administration of the initial dose of the folinicacid; and the folinic acid, fluorouracil, and irinotecan areadministered every 14 days.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a graph showing direct FACS binding of humanized monoclonalantibody 18G7H6A3 to human LGR5 (CHO).

FIG. 2 is a graph showing the effect of FOLFIRI, alone and incombination with 18G7H6A3, on CT3 CRC tumor volume.

FIG. 3 is a graph showing 18G7H6A3 treatment significantly reducedMDA-MB-231-LM3 primary tumor volume.

FIG. 4 shows graphs of FolFiri treatment in mice bearing CT1, or CT3tumors results in upregulation of LGR5.

FIG. 5 is a bar chart showing chemotherapy results in upregulation ofLGR5 (more than 4-fold) in JH109 tumors.

FIG. 6 is a graph showing significant activity of 18G7H6A3 observed whenadministered in combination with chemotherapy (gemcitabine).

FIG. 7 is a point plot showing that antibody 18G7H6A3 reduces the numberof live events in a CT1 cancer stem cell population.

FIG. 8 is a line graph showing cells isolated from mice treated withanti-LGR5 antibody 18G7H6A3 in combination with FOLFIRI had greatlydecreased tumorigenicity as compared to cells isolated from mice treatedwith FOLFIRI alone.

FIG. 9 is a line graph showing that re-implanted cells from the 18G7H6A3FOLFIRI combination had a significantly delayed time to progression.

FIG. 10 is a line graph showing significant activity of humanizedantibody 18G7H6A3 is observed when administered prophylactically incombination with chemotherapy (FOLFIRI).

FIG. 11 is a point plot showing that antibody 18G7H6A3 is able toinhibit Wnt signaling in tumor cells in vivo as indicated byphospho-Thr41/Ser45-β-catenin immunoassays.

FIG. 12 is a bar chart showing that increasing concentrations of solubleantibody 18G7H6A3 did not affect the induction of TCF/LEF promoterdriven GFP expression by the combination of Wnt3a plus RSPO2,demonstrating that the anti-LGR5 antibody 18G7H6A3 does not blockRSPO-driven TCF/LEF promoter activation. A positive control antibody C12is shown to inhibit Wnt3a/RSPO2 driven TCF/LEF promoter activitation.

FIG. 13 is a line graph showing that R-spondin does not block antibody18G7H6A3 binding to LGR5.

FIG. 14 is a bar chart showing that antibody 18G7H6A3 binding to LGR5inhibits formation of ternary complex.

FIG. 15 depicts levels of LGR5 expression in treated samples.

FIG. 16 depicts levels of CTNNB1 expression, and p-β-Catenin expressionin treated samples.

FIG. 17 depicts differentially expressed transcripts in various treatedsamples.

FIG. 18 depicts differentially expressed genes in 18G7H6A3- (BNC101)treated tumors.

FIG. 19 depicts differentially expressed genes in FOLFIRI treatedtumors.

FIG. 20 depicts differentially expressed genes in combination-treatedtumors

FIG. 21 depicts levels of LGR5 in circulating HLA+ cells.

FIG. 22A and FIG. 22B depict levels of LGR5 in circulating HLA+ cells.

FIG. 23 is a graph showing animal survival of mice treated withGemcitabine/Abraxane or with Gemcitabine/Abraxane and 18G7H6A3.

DETAILED DESCRIPTION

Some embodiments of the methods and compositions provided herein relateto administration of humanized antibodies or antigen-binding fragmentsthereof that specifically bind to leucine-rich repeat-containingG-protein coupled receptor 5 (LGR5) to treat certain cancers Anembodiment of such humanized antibodies and antigen-binding fragmentsthereof is disclosed in PCT Publication No. WO 2015/153916 publishedOct. 8, 2017 which is incorporated by reference in its entirety.

LGR5 was identified through lineage tracing studies as a highly specificmarker of normal stem cells and tumor-initiating cells in the gut.Previously about 150 genes were identified whose expression was quenchedfollowing abrogation of Wnt expression. A comprehensive characterizationof these ‘Wnt target genes’ found LGR5 to be selectively expressed on apopulation of 10-14 proliferating wedge-shaped cells at the crypt base.These crypt-based columnar cells were previously proposed to be acandidate stem cell population. Using in vivo lineage tracing with aheritable lacZ-LGR5 reporter gene, it has been confirmed that LGR5intestinal stem cells are a multi-potent, self-renewing population ofadult intestinal stem cells that give rise to uninterrupted ribbons oflacZ+ progeny cells initiating from the crypt base and extending to thevillus tips.

The specific expression of LGR5 on cancer stem cells (CSCs) provides anopportunity to target CSCs selectively and effectively. LGR5 is highlyover expressed in CRC, pancreatic and most other solid tumors, comparedto normal tissues, thereby providing a wide therapeutic window to targetCSCs in CRC, pancreatic, breast, ovarian, lung, gastric and livercancer.

The gate keeping mutation in CRC is loss of adenomatous polyposis coli(APC), resulting in the aberrant activation of Wnt signaling, whichnormally acts to regulate the balance between stem cell self-renewal anddifferentiation in the colon crypt. Dysregulated Wnt signaling inintestinal stem cells leads to the formation of adenomatous polyps inthe colon that are the precursor to malignant CRC. LGR5 stem cells wereconfirmed to be the source or root of these mouse intestinal tumors,using a strategy that crossed inducible APC gene knockout mice with micewhose LGR5 stem cells were specifically and randomly labeled with one offour (GFP/YFP/ECFP/RFP) fluorescent genetic markers. The appearance ofsingle colored tumors (i.e., all GFP or all RFP) 4 weeks after inductionof APC deletion confirmed that these tumors arose from a single LGR5stem cell. Furthermore, this model also allowed for the fluorescentgenetic tag in the LGR5 stem cells to be flipped to a different color,so that an RFP+ LGR5 cancer stem cell generating a red tumor could betransformed midstream into a ECFP+ LGR5 cancer stem cell, that was stillseeding the tumor but now giving rise to blue tumor cells invading thepreviously all red GFP+ tumor mass. This flipping experiment not onlyprovided further confirmation that LGR5 CSCs are the origin ofintestinal tumors, able to initiate and seed the growth of intestinaltumors, but also that they continuously maintain tumor formation (i.e.,have long-term repopulating ability).

A functional role of LGR5 in cancer has been validated throughribonucleic acid interference (RNAi) knockdown studies. Knockdown ofLGR5 in a panel of CRC tumor cell lines significantly inhibited thegrowth of soft agar colonies in vitro, and also the growth of HCT116colon tumor xenografts in vivo. LGR5 RNAi knockdown was subsequentlyshown to also reduce the growth of CSC colonies from patient-derived CRCtumor cells in vitro (data not shown). Finally, sorted LGR5+ PATIENTDERIVED XENOGRAFT CRC tumor cells were found to be highly tumorigenic invivo compared to control LGR5− cells.

CSCs are believed to responsible for the high incidence of tumorrecurrence in many cancer patients treated with surgery and standard ofcare chemotherapy. For example, CD44+ CSCs from breast cancer patientswere found to be enriched following chemotherapy, and that high levelsof CSCs correlated with poor clinical response to chemotherapy.Similarly, in metastatic CRC, LGR5 expression was upregulated in damagedliver following chemotherapy, suggesting that increased LGR5 CSCs inresponse to chemotherapy initiate and/or acerbate metastatic disease.Indeed, it has been found that LGR5 expression is significantly greaterin metastatic sites compared to primary CRC tumors.

Anti-LGR5 Antibodies

As used herein, the term “antibody” includes, but is not limited to,synthetic antibodies, monoclonal antibodies, recombinantly producedantibodies, intrabodies, multispecific antibodies (including bi-specificantibodies), human antibodies, humanized antibodies, chimericantibodies, synthetic antibodies, single-chain Fvs (scFv), Fabfragments, F(ab′) fragments, disulfide-linked Fvs (sdFv) (includingbi-specific sdFvs), and anti-idiotypic (anti-Id) antibodies, andepitope-binding fragments of any of the above. The antibodies of severalembodiments provided herein may be monospecific, bispecific, trispecificor of greater multispecificity. Multispecific antibodies may be specificfor different epitopes of a polypeptide or may be specific for both apolypeptide as well as for a heterologous epitope, such as aheterologous polypeptide or solid support material. See, e.g., PCTpublications WO 93/17715; WO 92/08802; WO91/00360; WO 92/05793; Tutt, etal., J. Immunol. 147:60-69 (1991); U.S. Pat. Nos. 4,474,893; 4,714,681;4,925,648; 5,573,920; 5,601,819; Kostelny et al., J. Immunol.148:1547-1553 (1992); each of which is incorporated herein by referencein its entirety.

As used herein, LGR5 includes, but is not limited to, human LGR5including the polypeptide of NCBI Accession No. NP 003658.1, orfragments thereof, which is encoded by the coding nucleotide sequencewithin NM 003667.2, or fragments thereof. The amino acid sequence andentire entry of NCBI Accession No. NP_003658.1 and nucleotide sequenceand entire entry of NM_003667.2 are fully incorporated by reference intheir entireties. Examples of LGR5 fragments contemplated herein includethe LGR5 ectodomain, transmembrane domain, or intracellular domain andportions thereof.

Several embodiments relate to a hybridoma that produces the light chainand/or the heavy chain of an anti-LGR5 antibody, including the anti-LGR5antibodies designated as 18G7H6A3 and 18G7H6A1 produced and described inthe Examples below. In one aspect, the hybridoma produces the lightchain and/or the heavy chain of a humanized or fully human monoclonalantibody such as that of 18G7H6A3 and 18G7H6A1 produced and described inthe Examples below.

Some embodiments are drawn to a nucleic acid molecule encoding the lightchain or the heavy chain of an anti-LGR5 antibody, including any one ofthe anti-LGR5 antibodies designated as 18G7H6A3 and 18G7H6A1 producedand described in the Examples below. In some aspects, a nucleic acidmolecule encodes the light chain or the heavy chain of a humanized orfully human monoclonal, such as antibody 18G7H6A3 and 18G7H6A1 producedand described in the Examples below.

Various embodiments are directed to a vector comprising a nucleic acidmolecule or molecules encoding a light chain and/or a heavy chain of ananti-LGR5 antibody, including any one of the anti-LGR5 antibodiesdesignated as 18G7H6A3 and 18G7H6A1 produced and described in theExamples below.

In various embodiments, the glycosylation of the antibodies can bemodified. For example, an aglycosylated antibody can be made (i.e., theantibody lacks glycosylation). Glycosylation can be altered to, forexample, increase the affinity of the antibody for a target antigen.Such carbohydrate modifications can be accomplished by, for example,altering one or more sites of glycosylation within the antibodysequence. For example, one or more amino acid substitutions can be madethat result in elimination of one or more variable region frameworkglycosylation sites to thereby eliminate glycosylation at that site.Such aglycosylation may increase the affinity of the antibody forantigen. Such an approach is described in further detail in U.S. Pat.Nos. 5,714,350 and 6,350,861; each of which is incorporated herein byreference in its entirety.

In several embodiments, the antibodies specifically bind a polypeptidecomprising or consisting of a LGR5 polypeptide having at least 60%identity, or at least 70% identity, or at least 80% identity, at least85% identity, at least 90% identity, at least 95% identity, or at leastat least 97% identity, or at least 99% identity, or 100% identity to thehuman LGR5 polypeptide of NCBI Accession Nos. NP_003658.1 (SEQ ID NO:47) or fragments thereof. Such fragments can, for example, be at leastabout 5, 10, 15, 20, 25, 50, 75, 100, 150, 200, 250, 300, 350, 400, 450,500, 550, 600, 650, 700, 750, 800, 850, or 900 contiguous ornon-contiguous amino acids of the LGR5 polypeptide, or any number ofcontiguous or non-contiguous amino acids in between any of theaforementioned lengths.

In several embodiments, the antibody is antibody 18G7H6A3 and comprisesa heavy chain amino acid sequence of SEQ ID NO: 13 and a DNA sequence ofSEQ ID NO: 11. In some embodiments, the antibody is antibody 18G7H6A3and has a heavy chain variable domain comprises SEQ ID NO: 19. Inseveral embodiments, the antibody is antibody 18G7H6A3 and comprises alight chain sequence of SEQ ID NO: 14. In other embodiments, theantibody is antibody 18G7H6A3 and comprises a light chain variabledomain of SEQ ID NO: 21.

In some embodiments the antibodies comprise a sequence that is 80%, 81%,82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%,96% 97%, 98%, 99%, or 100% identical to the sequence of the abovesequences. In some embodiments the antibodies comprise a sequence thatis 100% identical to the above antibody sequences over a span of 29, 30,31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48,49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66,67, 68, 69, 70, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83,84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100,101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114,115, 116, 117, or 118 residues of the heavy chain, light chain, orvariable domains of the above sequences.

In some embodiments the antibodies comprise a sequence that is 80%, 81%,82%, 83%, 84%, 85%, 86%, 87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%,96% 97%, 98%, 99%, or 100% identical to the antibody sequences. In someembodiments the antibodies comprise a sequence that is 84%, 85%, 86%,87%, 88%, 89%, 90%, 91%, 92%, 93%, 94%, 95%, 96% 97%, 98%, 99%, or 100%identical to the antibody sequences. In some embodiments the antibodiescomprise a sequence that is 100% identical to the antibody sequences ofover a span of 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46,47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64,65, 66, 67, 68, 69, 70, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81,82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99,100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, or 111 residues.

In some embodiments, an anti-LGR5 antibody provided herein comprises aheavy chain CDR1 comprising GYSFTAYW (SEQ ID NO:23), a heavy chain CDR2comprising ILPGSDST (SEQ ID NO:2), and a heavy chain CDR3 comprisingARSGYYGSSQY (SEQ ID NO:3). In some embodiments, an anti-LGR5 antibodyprovided herein comprises a light chain CDR1 comprising ESVDSYGNSF (SEQID NO:4), a light chain CDR2 comprising LTS, and a light chain CDR3comprising QQNAEDPRT (SEQ ID NO:33).

In some embodiments, an anti-LGR5 antibody provided herein comprises:(a) a heavy chain CDR1 comprising variants of the above sequences having1, 2, 3, or 4 amino acid substitutions. The antibody may also have aheavy chain CDR2 having a variant comprising 1, 2, 3, or 4 amino acidsubstitutions. The antibody may also have a heavy chain CDR3 having avariant comprising 1, 2, 3, or 4 amino acid substitutions. In additionto these modifications of the heavy chain, the antibody may also have alight chain CDR1 having a variant comprising 1, 2, 3, or 4 amino acidsubstitutions. The antibody may also have a light chain CDR2 having avariant comprising 1, 2, 3, or 4 amino acid substitutions. The antibodymay also have a light chain CDR3 having 1, 2, 3, or 4 amino acidsubstitutions. In some embodiments, the amino acid substitutions areconservative amino acid substitutions.

In some embodiments, an anti-LGR5 antibody provided herein comprises anantibody which comprises a heavy chain variable region having at least80% or 90% sequence identity to the sequences described herein in theattached sequence listing. The antibody may also have a light chainvariable region having at least 80% or 90% sequence identity to theantibody sequences described herein.

The percent identity of two amino acid sequences (or two nucleic acidsequences) can be determined, for example, by aligning the sequences foroptimal comparison purposes (e.g., gaps can be introduced in thesequence of a first sequence). The amino acids or nucleotides atcorresponding positions are then compared, and the percent identitybetween the two sequences is a function of the number of identicalpositions shared by the sequences (i.e., % identity=# of identicalpositions/total # of positions×100). The actual comparison of the twosequences can be accomplished by well-known methods, for example, usinga mathematical algorithm. A specific, non-limiting example of such amathematical algorithm is described in Karlin et al., Proc. Natl. Acad.Sci. USA, 90:5873-5877 (1993), which is incorporated herein by referencein its entirety. Such an algorithm is incorporated into the BLASTN andBLASTX programs (version 2.2) as described in Schaffer et al., NucleicAcids Res., 29:2994-3005 (2001), which is incorporated herein byreference in its entirety. When utilizing BLAST and Gapped BLASTprograms, the default parameters of the respective programs (e.g.,BLASTN) can be used. See http://www.ncbi.nlm.nih.gov, as available onApr. 10, 2002. In one embodiment, the database searched is anon-redundant (NR) database, and parameters for sequence comparison canbe set at: no filters; Expect value of 10; Word Size of 3; the Matrix isBLOSUM62; and Gap Costs have an Existence of 11 and an Extension of 1.

Several embodiments also encompass variants of the above describedantibodies, including any one of the anti-LGR5 antibodies designated as18G7H6A3 and 18G7H6A1 produced and described in the Examples below,comprising one or more amino acid residue substitutions in the variablelight (V_(L)) domain and/or variable heavy (V_(H)) domain. Several alsoencompass variants of the above described antibodies with one or moreadditional amino acid residue substitutions in one or more V_(L) CDRsand/or one or more V_(H) CDRs. The antibody generated by introducingsubstitutions in the V_(H) domain, V_(H) CDRs, V_(L) domain and/or V_(L)CDRs of the above described antibodies can be tested in vitro and invivo, for example, for its ability to bind to LGR5 (by, e.g.,immunoassays including, but not limited to ELISAs and BIAcore).

Various embodiments include antibodies that specifically bind to LGR5comprising derivatives of the V_(H) domains, V_(H) CDRs, V_(L) domains,or V_(L) CDRs of anti-LGR5 antibodies, such as any one of the anti-LGR5antibodies designated as 18G7H6A3 and 18G7H6A1 produced and described inthe Examples below, that specifically bind to LGR5. Standard techniquesknown to those of skill in the art can be used to introduce mutations(e.g., additions, deletions, and/or substitutions) in the nucleotidesequence encoding an antibody, including, for example, site-directedmutagenesis and PCR-mediated mutagenesis are routinely used to generateamino acid substitutions. In one embodiment, the V_(H) and/or V_(L) CDRsderivatives include less than 25 amino acid substitutions, less than 20amino acid substitutions, less than 15 amino acid substitutions, lessthan 10 amino acid substitutions, less than 5 amino acid substitutions,less than 4 amino acid substitutions, less than 3 amino acidsubstitutions, or less than 2 amino acid substitutions relative to theoriginal V_(H) and/or V_(L) CDRs. In another embodiment, the V_(H)and/or V_(L) CDRs derivatives have conservative amino acid substitutions(e.g. supra) made at one or more predicted non-essential amino acidresidues (i.e., amino acid residues which are not critical for theantibody to specifically bind to LGR5). Alternatively, mutations can beintroduced randomly along all or part of the Vu and/or V_(L) CDR codingsequence, such as by saturation mutagenesis, and the resultant mutantscan be screened for biological activity to identify mutants that retainactivity. Following mutagenesis, the encoded antibody can be expressedand the activity of the antibody can be determined.

Several embodiments also encompass antibodies that specifically bind toLGR5 or a fragment thereof, the antibodies comprising an amino acidsequence of a variable heavy chain and/or variable light chain that isat least 45%, at least 50%, at least 55%, at least 60%, at least 65%, atleast 70%, at least 75%, at least 80%, at least 85%, at least 90%, atleast 95%, or at least 99% identical to the amino acid sequence of thevariable heavy chain and/or light chain of any of the antibodiesdescribed herein including any one of the anti-LGR5 antibodies includingthose designated as 18G7H6A3 and 18G7H6A1 produced and described in theExamples below.

Another embodiment includes the introduction of conservative amino acidsubstitutions in any portion of an anti-LGR5 antibody, such as any oneof the anti-LGR5 antibodies designated as 18G7H6A3 and 18G7H6A1 producedand described in the Examples below. It is well known in the art that“conservative amino acid substitution” refers to amino acidsubstitutions that substitute functionally-equivalent amino acids.Conservative amino acid changes result in silent changes in the aminoacid sequence of the resulting peptide. For example, one or more aminoacids of a similar polarity act as functional equivalents and result ina silent alteration within the amino acid sequence of the peptide.Substitutions that are charge neutral and which replace a residue with asmaller residue may also be considered “conservative substitutions” evenif the residues are in different groups (e.g., replacement ofphenylalanine with the smaller isoleucine). Families of amino acidresidues having similar side chains have been defined in the art.Several families of conservative amino acid substitutions are shown inTable 1.

TABLE 1 Family Amino Acids non-polar Trp, Phe, Met, Leu, Ile, Val, Ala,Pro uncharged polar Gly, Ser, Thr, Asn, Gln, Tyr, Cys acidic/negativelycharged Asp, Glu basic/positively charged Arg, Lys, His Beta-branchedThr, Val, Ile residues that influence Gly, Pro chain orientationaromatic Trp, Tyr, Phe, HisBlocking Cancer Stem Cell Growth with Anti-LGR5 Antibodies

Several embodiments are drawn to blocking cancer stem cell growth invitro and in vivo with anti-LGR5 antibodies. In some embodiments, amethod of blocking cancer stem cell growth comprises administering aneffective amount of an anti-LGR5 antibody to cancer stem cells, whereinthe effective amount of the anti-LGR5 antibody is sufficient to reducegrowth of the cancer stem cells.

In some embodiments, a method of blocking cancer stem cell growthcomprises administering an effective amount of an anti-LGR5 antibody tocancer stem cells, wherein the effective amount of the anti-LGR5antibody is sufficient to reduce or block proliferation, or reduce orblock the growth, of the cancer stem cells.

In some aspects, an effective amount of an anti-LGR5 antibody isadministered to cancer stem cells in vitro. In other aspects, aneffective amount of an anti-LGR5 antibody is administered to cancer stemcells in a patient in need of treatment thereof, in vivo.

As used herein, the term “cancer stem cell(s)” refers to a cell that canproliferate extensively or indefinitely and give rise to a largeproportion of cancer cells in a cancer. In some aspects, the largeproportion of cancer cells represents a majority of the cancer cells ina given cancer. For illustration, but not limitation, a cancer stemcell(s) can be a founder of a tumor or a progenitor of the cancer cellsthat comprise the majority of a cancer's mass. In some aspects, cancerstem cells refer to cells that divide to form one or more tumors whenimplanted into an immunocompromised individual, in the absence of anyadditional mutation to the cells or introduction of exogenous cellproliferation-inducing or carcinogenic agents. In some aspects cancerstem cells divide to yield additional cancer stem cells as well asterminally differentiated cancer cells or cancer tissue.

In some embodiments cancer stem cell growth, proliferation, or viabilityis blocked without interfering with LGR5-RSpo binding or signaling. Insome embodiments cancer stem cell growth, proliferation, or viability isblocked without interfering with LGR5-RSpo binding or signaling throughblocking or inhibiting LGR5 signaling through Wnt.

As used with respect to blocking cancer stem cell growth, the term“effective amount” refers to an amount of anti-LGR5 antibody sufficientto reduce the growth of cancer stem cells by any degree. Any assay knownin the art can be used to measure cancer stem cell growth. For example,cancer stem cell growth can be measured by colony count, total cellcount, or volume/size of a cell population or colony. In severalembodiments, cancer stem cell growth can be measured by the tumor spheregrowth assay described below in Example 1.

In certain embodiments, an effective amount of an anti-LGR5 antibody canblock cancer stem cell growth as measured by at least a 5%, 10%, 15%,20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 95%, 96%, 97%, 98%, 99%, or 100%reduction in the cancer stem cell population or tumorsphere growth, orany percentage in between any of the aforementioned numbers. In someaspects, the anti-LGR5 antibody is any one or combination of theanti-LGR5 antibodies designated as 18G7H6A3 and 18G7H6A1 produced anddescribed in the Examples below.

For example, in some embodiments, an effective amount of an anti-LGR5antibody can block cancer stem cell growth as measured by at least about5%-99%, a 5%-80%, a 5 to 40%, a 10% to 99%, a 10 to 80%, a 10-60%, a10%-40%, a 20 to 99%, a 20%-80%, a 20%-60%, a 20%-40%, a 50%-98%,50%-80%, or a 60%-99% reduction in the cancer stem cell population ortumorsphere growth. In some aspects, the anti-LGR5 antibody is any oneor combination of the anti-LGR5 antibodies designated as 18G7H6A3 and18G7H6A1 produced and described in the Examples below.

In other embodiments, the effective amount of an anti-LGR5 antibody canblock cancer stem cell growth as measured by at least about a 1.1, 1.2,1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 2.0, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6,2.7, 2.8, 2.9, 3.0, 3.5, 4.0, 4.5, 5.0, 10, 25, 50, 75, 100, 200, or1000-fold reduction in the cancer stem cell population or tumorspheregrowth, or any fold-reduction in between any of the aforementionednumbers. In some aspects, the anti-LGR5 antibody is any one orcombination of the anti-LGR5 antibodies designated as 18G7H6A3 and18G7H6A1 produced and described in the Examples below.

In some embodiments, the effective amount of an anti-LGR5 antibodysufficient to block cancer stem cell growth by any degree describedabove is in a concentration of about 1 nM, 50 nM, 75 nM, 100 nM, 150 nM,200 nM, 250 nM, 300 nM, 350 nM, 400 nM, 500 nM, 550 nM, 600 nM, 700 nM,800 nM, 900 nM, 1 μM, 50 μM, 75 μM, 100 μM, 150 μM, 200 μM, 250 μM, 300μM, 350 μM, 400 μM, 500 μM, 550 μM, 600 μM, 700 μM, 800 μM, 900 μM, 1mM, 5 mM, 10 mM, 15 mM, 20 mM, 25 mM, 30 mM, 35 mM, 40 mM, 45 mM, 50 mM,75 mM, 100 mM, 200 mM, 300 mM, 400 mM, 500 mM, 600 mM, 700 mM, 800 mM,900 mM, 1000 mM, 1 M, 5 M, 10 M, 15 M, 20 M, 25 M, 30 M, 35 M, 40 M, 45M, 50 M, 75 M, 100 M, or any number in between any two of theaforementioned concentrations. In some aspects, an anti-LGR5 antibodycomposition may comprise both of antibodies designated as 18G7H6A3 and18G7H6A1 produced and described in the Examples below.

In some embodiments, an anti-LGR5 antibody provided herein binds humanLGR5 with a KD of less than about 200 nM, less than about 100 nM, lessthan about 80 nM, less than about 50 nM, less than about 20 nM, lessthan about 10 nM, less than about 1 nM, and a range between any of theforegoing values. In some embodiments, an anti-LGR5 antibody providedherein binds LGR5 with an affinity less than about 10 nM, 5 nM, 4 nM, 3nM, 2 nM, 1 nM, and within a range of any of the foregoing values. Insome embodiments, an anti-LGR5 antibody provided herein binds LGR5 withan affinity greater than about 0.0001 nM, 0.001 nM, 0.01 nM, and withina range of any of the foregoing values.

In some embodiments, an anti-LGR5 antibody provided herein binds to anepitope comprising or consisting of or within amino acids T175, E176,Q180, R183, S186, A187, Q189, D247, E248, T251, R254, 5257, N258, K260of SEQ ID NO: 47. In some embodiments, an anti-LGR5 antibody providedherein binds to an epitope comprising or consisting of or within leucinerich repeats 6-9 (See e.g., Chen et al. Genes Dev. 27(12):1345-50 whichis incorporated by reference in its entirety). In some embodiments, ananti-LGR5 antibody provided herein binds to an epitope comprising orconsisting of or within the convex surface of the LGR5 ecto domain (Seee.g., Chen et al. Genes Dev. 27(12):1345-50 which is incorporated byreference in its entirety).

Some embodiments include methods of treating cancer comprisingadministering a therapeutically effective amount of an anti-LGR5antibody provided herein to a subject in need thereof. In someembodiments, the cancer is selected from pancreatic cancer, colorectalcancer, lung cancer, pancreatic cancer, and breast cancer, such astriple negative breast cancer. In some embodiments, the colorectalcancer comprises an inactivating mutation in the adenomatous polyposiscoli (APC) gene, does not comprise an inactivating mutation in the APCgene, or comprises a wild-type APC gene. In some embodiments, the canceris. In some embodiments, the cancer comprises elevated levels of LGR5protein. In some embodiments, the cancer is colon cancer that expresseselevated levels of LGR5. In some embodiments, the cancer is a pancreaticcancer that expresses elevated levels of LGR5, In some embodiments, thecancer is a breast cancer that expresses elevated levels of LGR5.

Some embodiments include methods of treating a disease in a subjectwherein the disease is associated with activation of β-catenin, and/oraberrant β-catenin signaling. Some embodiments include administering atherapeutically effective amount of an anti-LGR5 antibody providedherein to a subject in need thereof.

Some embodiments include methods of treating a disease comprisingadministering a therapeutically effective amount of an anti-LGR5antibody provided herein to a subject in need thereof in combinationwith at least one additional therapeutic agent. In some embodiments, theadditional therapeutic agent comprises a chemotherapeutic agent. In someembodiments, the additional therapeutic agent comprises a biologicagent. Some embodiments include administering an anti-LGR5 antibodyprovided herein in combination with a chemotherapeutic agent and abiologic agent. In some embodiments, administering an anti-LGR5 antibodyprovided herein in combination with a chemotherapeutic agent canincrease the expression level of LGR5 in a cancer, such as a tumor. Someembodiments of the methods provided herein include determining the levelof LGR5 protein expression in a tumor or cancer.

Some embodiments of the methods provided herein include identifying asubject for treatment with an anti-LGR5 antibody provided herein. Someembodiments include determining if the subject has a tumor comprising anelevated expression level of LGR5 as compared to the expression of thesame LGR5 protein in normal tissue. Some embodiments include selecting asubject for treatment if the tumor has an elevated level of LGR5expression. Some embodiments also include determining if the subject hasa tumor that comprises an inactivating mutation in the APC gene. Someembodiments also include selecting a subject for treatment if the tumorcomprises an inactivating mutation in the APC gene.

Methods, compositions and related disclosure relevant to the above areprovided in, for example, PCT Publication No. WO 2013/067055, publishedMay 10, 2013, the contents of which are hereby incorporated by referencein their entirety, as well as for example, PCT Publication No. WO2013/067054, published May 10, 2013, the contents of which are herebyincorporated by reference in their entirety, as well as for example, PCTPublication No. WO 2013/067057, published May 10, 2013, the contents ofwhich are hereby incorporated by reference in their entirety, as well asfor example, PCT Publication No. WO 2013/067060, published May 10, 2013,the contents of which are hereby incorporated by reference in theirentirety.

Pharmaceutical Compositions

The humanized monoclonal antibody or an antigen-binding fragment thereofthat specifically binds LGR5 provided herein, can be incorporated intopharmaceutical compositions suitable for administration. Suchcompositions typically comprise the humanized monoclonal antibody or anantigen-binding fragment thereof and a pharmaceutically acceptablecarrier. As used herein, the term “pharmaceutically acceptable carrier”is intended to include any and all solvents, dispersion media, coatings,antibacterial and antifungal agents, isotonic and absorption delayingagents, and the like, compatible with pharmaceutical administration.Suitable carriers are described in the most recent edition ofRemington's Pharmaceutical Sciences, a standard reference text in thefield, which is incorporated herein by reference. Preferred examples ofsuch carriers or diluents include, but are not limited to, water,saline, ringer's solutions, dextrose solution, and 5% human serumalbumin. Liposomes and non-aqueous vehicles such as fixed oils may alsobe used. The use of such media and agents for pharmaceutically activesubstances is well known in the art. Except insofar as any conventionalmedia or agent is incompatible with the active compound, use thereof inthe compositions is contemplated. Supplementary active compounds canalso be incorporated into the compositions.

A pharmaceutical composition of the invention is formulated to becompatible with its intended route of administration. Examples of routesof administration include parenteral, e.g., intravenous, intradermal,subcutaneous, oral (e.g., inhalation), transdermal (i.e., topical),transmucosal, and rectal administration. Solutions or suspensions usedfor parenteral, intradermal, or subcutaneous application can include thefollowing components: a sterile diluent such as water for injection,saline solution, fixed oils, polyethylene glycols, glycerine, propyleneglycol or other synthetic solvents; antibacterial agents such as benzylalcohol or methyl parabens; antioxidants such as ascorbic acid or sodiumbisulfite; chelating agents such as ethylenediaminetetraacetic acid(EDTA); buffers such as acetates, citrates or phosphates, and agents forthe adjustment of tonicity such as sodium chloride or dextrose. The pHcan be adjusted with acids or bases, such as hydrochloric acid or sodiumhydroxide. The parenteral preparation can be enclosed in ampoules,disposable syringes or multiple dose vials made of glass or plastic.

Pharmaceutical compositions suitable for injectable use include sterileaqueous solutions (where water soluble) or dispersions and sterilepowders for the extemporaneous preparation of sterile injectablesolutions or dispersion. For intravenous administration, suitablecarriers include physiological saline, bacteriostatic water, CremophorEL® (BASF, Parsippany, N.J.) or phosphate buffered saline (PBS). Thecarrier can be a solvent or dispersion medium containing, for example,water, ethanol, polyol (for example, glycerol, propylene glycol, andliquid polyethylene glycol, and the like), and suitable mixturesthereof. In many cases, it will be preferable to include isotonicagents, for example, sugars, polyalcohols such as manitol, sorbitol,sodium chloride in the composition. Prolonged absorption of theinjectable compositions can be brought about by including in thecomposition an agent which delays absorption, for example, aluminummonostearate and gelatin.

Sterile injectable solutions can be prepared by incorporating the activecompound in the required amount in an appropriate solvent with one or acombination of ingredients enumerated above, as required, followed byfiltered sterilization. Generally, dispersions are prepared byincorporating the active compound into a sterile vehicle that contains abasic dispersion medium and the required other ingredients from thoseenumerated above. In the case of sterile powders for the preparation ofsterile injectable solutions, methods of preparation are vacuum dryingand freeze-drying that yields a powder of the active ingredient plus anyadditional desired ingredient from a previously sterile-filteredsolution thereof.

It is especially advantageous to formulate compositions in dosage unitform for ease of administration and uniformity of dosage. Dosage unitform as used herein refers to physically discrete units suited asunitary dosages for the subject to be treated; each unit containing apredetermined quantity of active compound calculated to produce thedesired therapeutic effect in association with the requiredpharmaceutical carrier. The specification for the dosage unit forms ofthe invention are dictated by and directly dependent on the uniquecharacteristics of the active compound and the particular therapeuticeffect to be achieved, and the limitations inherent in the art ofcompounding such an active compound for the treatment of individuals.

The pharmaceutical compositions can be included in a container, pack, ordispenser together with instructions for administration.

Kits

Some embodiments provided herein include kits. In some embodiments, akit can include a humanized antibody provided herein. In someembodiments, the antibody is lyophilized. In some embodiments, theantibody is in aqueous solution. In some embodiments, the kit includes apharmaceutical carrier for administration of the antibody. In someembodiments, the kit also includes a chemotherapeutic agent. In someembodiments, the chemotherapeutic agent is selected from folinic acid,fluorouracil, irinotecan, gemcitabine and nanoparticle albumin-boundpaclitaxel (ABRAXANE).

Some embodiments include a container comprising a pharmaceuticalcomposition comprising a dose of humanized monoclonal antibody or anantigen-binding fragment thereof that specifically binds LGR5, and asuitable pharmaceutical carrier, in which the dose is suitable to treata subject having a cancer. The dose of the humanized monoclonal antibodyor an antigen-binding fragment can be greater than, less than or equalto about 1 mg/kg, 2 mg/kg, 5 mg/kg, 10 mg/kg, 15 mg/kg, 20 mg/kg, 25mg/kg, 30 mg/kg, 35 mg/kg, 40 mg/kg, 45 mg/kg, 50 mg/kg, 55 mg/kg, 60mg/kg, 65 mg/kg, 70 mg/kg, or a range between any two of the foregoingdosages. In some embodiments, the dose of the humanized monoclonalantibody or an antigen-binding fragment thereof is between about 2.5mg/kg to about 20 mg/kg, or between about 2.5 mg/kg to about 15 mg/kg.In some embodiments, the pharmaceutical composition is suitable forintravenous administration. In some embodiments, the pharmaceuticalcomposition is suitable for intraperitoneal injection.

Methods of Treatment

Some embodiments of the methods, compositions and kits include methodsof treating a subject having a cancer. Some such methods includeadministering an effective amount of a humanized monoclonal antibody oran antigen-binding fragment thereof that specifically binds LGR5 to asubject in need thereof. The subject can be mammalian, for example,human.

In some embodiments, the cancer comprises a solid tumor. In someembodiments, the cancer can be a colon cancer, colorectal cancer, apancreatic cancer, a breast cancer, or a lung cancer. In someembodiments, the cancer can be a colon cancer comprising an APCmutation, a colon cancer comprising an KRAS mutation, a metastaticcolorectal cancer, a metastatic pancreatic cancer, a triple-negativebreast cancer, or a small cell lung cancer.

The humanized monoclonal antibody or an antigen-binding fragment thereofthat specifically binds LGR5 can include a heavy chain CDR, such a heavychain CDR1 comprising SEQ ID NO:23, a heavy chain CDR2 comprising SEQ IDNO:25, and/or a heavy chain CDR3 comprising SEQ ID NO:27. In someembodiments, the monoclonal antibody or antigen-binding fragment thereofcan include a heavy chain variable domain comprising SEQ ID NO:19. Insome embodiments, the monoclonal antibody or antigen-binding fragmentthereof can include a heavy chain comprising SEQ ID NO:13. In someembodiments, the monoclonal antibody or antigen-binding fragment thereofcan include a light chain CDR, such as a light chain CDR1 comprising SEQID NO:29, a light chain CDR2 comprising SEQ ID NO:31, and/or a lightchain CDR3 comprising SEQ ID NO:33. In some embodiments, the monoclonalantibody or antigen-binding fragment thereof can include a light chainvariable domain comprising SEQ ID NO:21. In some embodiments, themonoclonal antibody or antigen-binding fragment thereof can include alight chain comprising SEQ ID NO:14. In some embodiments, the monoclonalantibody or antigen-binding fragment thereof can include a heavy chaincomprising SEQ ID NO:13 and a light chain comprising SEQ ID NO:14. Insome embodiments, the humanized monoclonal antibody or anantigen-binding fragment thereof is 18G7H6A3.

The dosage of the humanized monoclonal antibody or an antigen-bindingfragment thereof to treat a subject having a cancer can be greater than,less than or equal to about 1 mg/kg, 2 mg/kg, 5 mg/kg, 10 mg/kg, 15mg/kg, 20 mg/kg, 25 mg/kg, 30 mg/kg, 35 mg/kg, 40 mg/kg, 45 mg/kg, 50mg/kg, 55 mg/kg, 60 mg/kg, 65 mg/kg, 70 mg/kg, or a range between anytwo of the foregoing dosages. In some embodiments, the dosage of thehumanized monoclonal antibody or an antigen-binding fragment thereof isbetween about 2.5 mg/kg to about 20 mg/kg, or between about 2.5 mg/kg toabout 15 mg/kg.

The frequency of administration of the humanized monoclonal antibody oran antigen-binding fragment thereof can be daily, weekly, or monthly. Insome embodiments, administration can be once a day, every 2 days, every3 days, every 4 days, every 5 days, or every 6 days. In someembodiments, administration can be once a week, every 2 weeks, every 3weeks, or every 4 weeks. In some embodiments, administration can bemonthly.

The route of administration of the humanized monoclonal antibody or anantigen-binding fragment thereof can be suitable for administration of abiologic. For example, administration can be via an intraperitonealinjection, or via an intravenous route.

Administration of the humanized monoclonal antibody or anantigen-binding fragment thereof can be in combination with achemotherapeutic agent. Examples of chemotherapeutic agents includefolinic acid (leucovorin), fluorouracil (5-FU), irinotecan, gemcitabineand nanoparticle albumin-bound paclitaxel (ABRAXANE). In someembodiments, the FOLFIRI combination: folinic acid, fluorouracil, andirinotecan, can be administered in combination with the humanizedmonoclonal antibody or an antigen-binding fragment thereof. In someembodiments, the initial dose of a chemotherapeutic agent in a method totreat a cancer in combination with a humanized monoclonal antibody or anantigen-binding fragment thereof can be administered prior toadministration of an initial dose the humanized monoclonal antibody oran antigen-binding fragment thereof. In some embodiments, the initialdose of a chemotherapeutic agent in a method to treat a cancer incombination with a humanized monoclonal antibody or an antigen-bindingfragment thereof can be administered after administration of an initialdose the humanized monoclonal antibody or an antigen-binding fragmentthereof.

In some embodiments, an initial dose of the irinotecan can be about 180mg/m² administered over about 90 minutes; an initial dose of the folinicacid is about 400 mg/m² administered over about 120 minutes andconcurrently with the initial dose of the irinotecan; and/or an initialdose of the fluorouracil is about 400 mg/m² administered afteradministration of the initial dose of the folinic acid. In someembodiments, the folinic acid, fluorouracil, and irinotecan areadministered every 14 days.

In some embodiments, the humanized monoclonal antibody or anantigen-binding fragment thereof can be administered in combination withan additional therapeutic agent. Examples of additional therapeuticagent include bevacizumab, aflibercept, cetuximab, and panitumumab.

EXAMPLES Example 1—Humanization of LGR5 Antibody

Human germline sequences were used as the acceptor frameworks forhumanizing the murine antibody 18G7.1. To find the closest germlinesequences, the most similar expressed light chain and the most similarheavy chain were identified in a database of germline sequences by NCIIgBLAST (ncbi.nlm.nih.gov/igblast/). In this search the CDR sequences of18G7.1 were masked. The selection of the most suitable expressedsequence included checking for sequence identity of the canonical andinterface residues, and checking for the similarity in CDR loop lengths.

In order to identify potential structural conflicts in key structuralframework residues between the candidate humanized sequence and theparent murine monoclonal antibody 18G7.1, a three-dimensional model wasgenerated. A composite of antibody structures was used to create ahomology model with grafted candidate humanized sequences followed bymolecular energy minimization. Structural analysis using computersoftware Pymol, was used to identify residues that could potentiallynegatively impact proper folding.

From this analysis, six candidate VH chains were constructed thatincluded: 1) a functional human framework containing selectedsubstitutions within the candidate humanized framework region based onanalysis of likely impact on folding and ii) the parental 18G7.1 murineantibody CDRs (SEQ ID NOs: 1, 2, and 3). fused in-frame to the humanIgG1 constant region are chemically synthesized.

Similarly, two candidate VL chains were constructed that included: 1) afunctional human framework containing selected substitutions within thecandidate humanized framework region based on analysis of likely impacton folding and ii) the parental 18G7.1 murine antibody CDRs (SEQ ID NOs:4, 5, and 6). The candidate VL chain and the candidate VH chain fusedin-frame to the human IgG1 constant region were chemically synthesized.

Selected candidate variant humanized heavy and light chain combinationswere tested for functionality by co-transfection into mammalian cells.Each of the six candidate humanized 18G7.1 heavy chains described abovewere co-transfected with one of the candidate 18G7.1 light chains intoHEK 293 cells, and conditioned media was assayed for LGR5 antigenbinding activity by flow cytometry. In addition, three candidatehumanized 18G7.1 heavy chains described above were co-transfected withthe second candidate 18G7.1 light chain into HEK 293 cells, andconditioned media was assayed for LGR5 antigen binding activity by flowcytometry. The 18G7.1 candidate heavy chain/light chain combination(humanization variant) known as 18G7H6, and which exhibited the mostrobust binding was selected for affinity maturation.

Example 2—Humanized LGR5 Antibody Affinity Maturation

In order to increase the affinity of the selected humanized variant18G7H6, a combination of alanine scanning mutagenesis and saturationmutagenesis was employed. Residues in heavy chain CDR1 and light chainCDR1 and CDR3 were mutated to alanine, transfected into HEK 293 cells,and the resultant conditioned media was assayed for LGR5 antigen bindingactivity by flow cytometry. Saturation mutagenesis was performed onheavy chain CDR3, in which every residue in CDR3 was mutated to each ofthe 19 naturally occurring amino acids except the original amino acididentity at that position. Each of the mutants were transfected into HEK293 cells, and the resultant conditioned media was assayed for LGR5antigen binding activity by flow cytometry.

These mutations were incorporated at increasing number into 3constructs. These three constructs were then transfected into HEK 293cells, and the resultant conditioned media was assayed for LGR5 antigenbinding activity by flow cytometry. Two constructs 18G7H6A1 and 18G7H6A3were selected for further characterization. TABLE 1A lists certainsequences of the antibodies.

TABLE 1A Description SEQ ID NO: 18G7.1 Heavy Chain CDR1 Amino Acid 118G7.1 Heavy Chain CDR2 Amino Acid 2 18G7.1 Heavy Chain CDR3 Amino Acid3 18G7.1 Light Chain CDR1 Amino Acid 4 18G7.1 Light Chain CDR2 AminoAcid 5 18G7.1 Light Chain CDR3 Amino Acid 6 18G7H6A1 Heavy Chain DNA 718G7H6A1 Light Chain DNA 8 18G7H6A1 Heavy Chain Amino Acid 9 18G7H6A1Light Chain Amino Acid 10 18G7H6A3 Heavy Chain DNA 11 18G7H6A3 LightChain DNA 12 18G7H6A3 Heavy Chain Amino Acid 13 18G7H6A3 Light ChainAmino Acid 14 18G7Ch Heavy Chain DNA 15 18G7Ch Light Chain DNA 16 18G7ChHeavy Chain Amino Acid 17 18G7ch Light Chain Amino Acid 18 18G7H6A3Heavy Chain Variable Domain Amino Acid 19 18G7H6A3 Heavy Chain VariableDomain DNA 20 18G7H6A3 Light Chain Variable Domain 21 18G7H6A3 LightChain Variable Domain DNA 22 18G7H6A3 Heavy Chain CDR1 Amino Acid 2318G7H6A3 Heavy Chain CDR1 DNA 24 18G7H6A3 Heavy Chain CDR2 Amino Acid 2518G7H6A3 Heavy Chain CDR2 DNA 26 18G7H6A3 Heavy Chain CDR3 Amino Acid 2718G7H6A3 Heavy Chain CDR3 DNA 28 18G7H6A3 Light Chain CDR1 Amino Acid 2918G7H6A3 Light Chain CDR1 DNA 30 18G7H6A3 Light Chain CDR2 Amino Acid 3118G7H6A3 Light Chain CDR2 DNA 32 18G7H6A3 Light Chain CDR3 Amino Acid 3318G7H6A3 Light Chain CDR3 DNA 34 18G7H6A1 Heavy Chain CDR1 Amino Acid 3518G7H6A1 Heavy Chain CDR1 DNA 36 18G7H6A1 Heavy Chain CDR2 Amino Acid 3718G7H6A1 Heavy Chain CDR2 DNA 38 18G7H6A1 Heavy Chain CDR3 Amino Acid 3918G7H6A1 Heavy Chain CDR3 DNA 40 18G7H6A1 Light Chain CDR1 Amino Acid 4118G7H6A1 Light Chain CDR1 DNA 42 18G7H6A1 Light Chain CDR2 Amino Acid 4318G7H6A1 Light Chain CDR2 DNA 44 18G7H6A1 Light Chain CDR3 Amino Acid 4518G7H6A1 Light Chain CDR3 DNA 46 LGR5 Amino Acid Sequence 47 18G7H6A1Heavy Chain Variable Amino acid 48 18G7H6A1 Light Chain Variable Aminoacid 49

Example 3—Production of Humanized LGR5 Antibodies

GS single gene vectors for 18G7H6A1, 18G7H6A3 and a chimeric 18G7.1(murine Fab from 18G7.1 fused to human IgG1 Fc), named 18G7Ch wereconstructed, amplified and transiently co-transfected into ChineseHamster Ovary cells (CHOK1SV GS-KO) using transient transfection forexpression evaluation at a volume of 200 ml. Large scale transienttransfection of CHOK1SV GS-KO cells at a final volume of 5 litres for18G7CH and 2.5 litres for both 18G7H6A1 and 18G7H6A3 was then initiated.Clarified culture supernatant was purified using one-step Protein Achromatography. Product quality analysis in the form of SE-HPLC,SDS-PAGE and endotoxin measurement was carried out using purifiedmaterial at a concentration of 1 mg/ml including an in-house humanantibody as a control sample. Results showed high purity of productrecovered (>95.7%).

Example 4—Construction of the Cell Line for a Humanized LGR5 Antibody

Stable GS-CHO transfectant pools, expressing the 18G7H6A3 antibody werecreated by transfection of CHOK1SV GS-KO host cells with the expressionvector p18G7H6A3/DGV. The DGV containing the gene encoding the antibodywas constructed, transfected and resultant clonal cell lines weresubsequently generated by single cell sorting of the transfectant poolsusing a FACS method. The 96-well plates generated during cloning werescreened weekly for the presence of single colonies. After approximately2 weeks, supernatant from up 1000 colonies were screened for antibodyproduction using an Octet® System method. Of the 1000 colonies screened,991 produced detectable levels of antibody. The Octet data were rankedand the highest producing colonies were selected for progression.

The highest ranked colonies were progressed to suspension culture in96-deep well plates in CD CHO medium and were subsequently adapted tosubculture medium. Productivity of the selected cell lines wereperformed using a feed regime which mimicked, as closely as possible,the bioreactor process. The cultures were harvested on day 12 andassayed for antibody concentration using an Octet® System method.Antibody concentrations at harvest ranged from <20 mg/L to 3000 mg/L.Twenty cell lines were selected for further evaluation based upon rankposition in the productivity screen, the parental pool from which thecell line was derived and evidence that each cell line arose from asingle colony. The cultures of the 20 selected cell lines were expandedby serial subculture from 96 deep well plates to shake-flasks. Basedupon rank position in the ‘abridged’ fed-batch suspension cultureproductivity screen and having acceptable growth characteristics duringroutine subculture in shake-flask cultures (consistently ≥1×106 viablecells per mL at routine subculture), the lead cell line selected forevaluation in two 10 L laboratory-scale stirred-tank bioreactors. Thislead cell line demonstrated consistently high growth and viabilityduring routine subculture and has >2000 mg/L titers at harvest. Thiscell line was used for creation of the Master Cell Bank (MCB) and forevaluation in 10 L laboratory-scale bioreactors

Example 5—Humanized LGR5 Antibody Binds to Human LGR5

A FACS-based assay was used to measure the binding of purified 18G7H6A1and 18G7H6A3 to recombinant human LGR5 overexpressed on the surface ofCHO cells. CHO and CHO-LGR5 cells were stained with serial dilutions of18G7H6A1 or 18G7H6A3 at 4° C., surface staining was detected withPE-conjugated anti-human IgG secondary antibodies and analyzed on theFACScalibur. The EC50 of 18G7H6A1 and 18G7H6A3 for human LGR5 bindingwas <10 nM. An antibody control (MOPC) was used as a negative control inthis experiment as well as wild-type CHO without LGR5. 18G7H6A3 showedno binding to the wild-type CHO and the isotype control did not show anymeasurable binding to human LGR5.

To identify potential animal model species for investigating thetherapeutic efficacy and safety of 18G7H6A3, the cross-reactivity of18G7H6A3 to LGR5 expressed by species homologues was determined in aseries of in vitro binding studies. See FIG. 1. As shown, antibody18G7H6A3 (BNC101) was found to strongly bind human and cyno LGR5, butnot bind to rat or mouse LGR5.

Example 6—Binding of a Humanized LGR5 Antibody to Plate-BoundRecombinant, Human LGR5 Ectodomain

Binding of 18G7H6A1 and 18G7H6A3 to human LGR5 was assessed in vitrousing an ELISA-based plate binding assay. The assay measured antibodybinding to ELISA plate-bound purified recombinant, LGR5ectodomain-IgG-Fc fusion, with detection of LGR5-bound antibody withhorseradish peroxidase-conjugated anti-human IgG-CH1 secondary antibody.The EC50 of 18G7H6A3 for human LGR5-Fc was found to be 300 pM.

Example 7—Binding Characteristics of a Humanized LGR5 Antibody on TumorCells

The binding characteristics of 18G7H6A3 to human cancer cell linesexpressing different levels of LGR5, were analyzed by flow cytometry todefine the potential targeting properties of 18G7H6A3 on heterogeneoustumor populations. The expression levels of LGR5 in multiple tumor celllines were quantified by flow cytometry.

Human tumor cell lines analyzed in these studies included coloncarcinoma cancer cell lines (CT1 (Bionomics), CT3 (Bionomics), DLD1(ATCC), Ls174T (ATCC), LoVo (ATCC), SW48 (ATCC), SW480 (ATCC), SW620(ATCC) and HCT116 (ATCC)), triple negative breast cancer cell lines(Hs578T (ATCC) and MDA-MB-231 (ATCC)), pancreatic cancer cell lines(AsPC-1 (ATCC), BxPC3 (ATCC), Capan2 (ATCC), HPAFII (ATCC), SW1990(ATCC), CFPAC (ATCC), Panc10.05 (ATCC) and PANC-1 (ATCC)),cisplatin-sensitive ovarian cancer cell lines (OVCAR3 (ATCC) and SK-OV-3(ATCC)), cisplatin-resistant ovarian cancer cell lines (SK-OV-3/CP,OVCAR8/CP, Igrov1/CP and A2780/CP (TGEN)) and lung adenocarcinoma cellline HOP62 (ATCC).

Cells grown near confluence were lifted with TrypLE cell dissociationbuffer (Life Technologies), counted and plated in 96-well V-bottomplates at 1×105 cells per well. 18G7H6A3 was tested at a startingconcentration of 100 nM with serial dilutions in staining buffer(PBS/0.8% bovine serum albumin). Samples were incubated on ice for 30minutes, then centrifuged at 1800 rpm for 2 minutes at 4° C. and washed3 times with staining buffer. Fifty μk of secondary antibody goatanti-human IgG-PE conjugate at 1:250 dilution (Southern Biotech) wasadded to each corresponding well in staining buffer. Samples wereincubated for an additional 15 minutes on ice, and then washed asdescribed above and resuspended in 100 μl staining buffer containingpropidium iodide (PI) (Life Technologies) for dead cell exclusion.Samples were analyzed on the FACScalibur flow cytometer using CellQuest(Becton Dickinson) and FlowJo (TreeStar, Inc) software.

The cell surface expression levels of LGR5 in multiple tumor cell lineswere quantified by flow cytometry. CT1 colorectal tumor cells andpancreatic cancer cell lines Panc-1, Capan2 and CFPAC were among thehighest LGR5 expressors. Moderate expression levels were observed inpancreatic cancer cell lines (AsPC-1, SW1990, HPAFII),cisplatin-resistant ovarian cancer cell lines (OVCAR8/CP, A2780/CP andIgrov1/CP) as well as colon, breast and ovarian cancer cell lines (SW48,Hs578T and OVCAR3). Low but detectable levels of LGR5 cell surfaceexpression were observed in colon (SW480, LoVo) and breast cancer celllines (MDA-MB-231). Table 2 summarizes the data for 18G7H6A3 FACSbinding to Tumor cell lines.

TABLE 2 Tumor Cell line 18G7H6A3 (18G7.1) IgG CRC CT1 + − CT3 + − DLD1+/− − Ls174T +/− − LoVo +/− − SW48 + − SW480 +/− − SW620 +/− − HCT116+/− − Breast MDA-MB-231 +/− − MDA-MB-231 LM2 +/− − Hs578T + − CN34 +/− −CN34 LM1 +/− − Prostate PC-3 +/− − PCSD1 +/− − Ovarian OVCAR-3 + −SK-OV-3 +/− − SK-OV-3/CP +/− − OVCAR8/CP + − Igrov1/CP + − A2780/CP + −Lung HOP-62 +/− − Pancreatic AsPC-1 + − Capan2 ++ − HPAFII + − Swl990* +− CFPAC ++ − PANC-1 ++ −

Example 8—Inhibition of Cachectic Colorectal Tumor Growth In Vivo by aHumanized Anti-LGR5 Antibody

The CT1 primary CRC xenograft model was derived from a patient withstage IV metastatic colon cancer. DNA sequencing of this tumoridentified common colon cancer mutations in multiple genes includingK-Ras, PI3K, PTEN, p53 and APC. Low passage CT1 tumorspheres maintainedin culture under serum-free conditions were injected into SCID/Bg micein Matrigel subcutaneously on day 0, and monitored twice weekly fortumor size and body weight. At day 25 CT1 subcutaneous tumors wererandomized into groups of 10 mice when tumors reached 120 mm3. Mice weretreated with either PBS, antibody control MOPC, 18G7H6A1, 18G7H6A3 orhuman/murine chimeric 18G7Ch. Mice were dosed BIW at 15 mg/kg for 2.5weeks (5 doses total).

Antibody 18G7H6A3 showed significant anti-tumor activity in vivocompared to PBS and MOPC antibody controls during the course of 4 doses(15 mg/kg, twice weekly). While antibody 18G7H6A1 showed anti-tumoractivity, monoclonal 18G7H6A3 showed superior activity to both 18G7H6A1and the parental murine chimeric 18G7Ch antibody. Table 3 shows percentCT1 tumor volume reduction (group vs MOPC) after 1-4 doses of Lgr5+ Abs.

TABLE 3 # of Doses: 1 2 3 4 18G7Ch 9.2% 30.6% 19.5% 29.0% 18G7H6A1 17.5%19.1% 14.2% 19.0% 18G7H6A3 38.8% 42.0% 28.9% 35.4%

Example 9—Inhibition of Colorectal Tumor Growth In Vivo by a HumanizedAnti-LGR5 Antibody

The CT3 primary CRC xenograft model was derived from a patient withstage III mCRC with mutations in K-Ras, H-Ras, APC, PI3K, PTEN, STK11,RB1, TP53, FGFR2, VANGL2, and ISCO. Low passage cryopreserved CT3primary xenograft tumor fragments were implanted into 5 SCID/Bg mice.Tumors averaging ˜1150 mm3 pooled from five CT3 primaryxenograft-bearing SCID mice were removed at day 41 post-implant,dissociated and re-implanted into CB.17 SCID mice in Matrigelsubcutaneously, and monitored twice weekly for tumor size and bodyweight. When tumors reached an average of 130 mm3, mice were randomized(34 days post implant). Mice were treated with either PBS, antibodycontrol MOPC, 18G7H6A3, 18G7H6A1 or human/murine chimeric 18G7Ch. Micewere dosed BIW at 15 mg/kg for 2.5 weeks (5 doses), starting on day 34.All mice were monitored twice weekly for body weight and tumor size, aswell as overall health and appearance, until termination.

While antibody 18G7H6A1 showed anti-tumor activity, monoclonal 18G7H6A3showed significant anti-tumor activity compared to PBS and MOPC antibodycontrols after 4 doses (15 mg/kg, twice weekly). 18G7H6A3 showedsuperior activity to the parental murine chimeric 18G7Ch antibody andequivalent activity to 18G7H6A1. Table 4 shows percent CT3 tumor volumereduction (group vs MOPC) after n dose of test Abs.

TABLE 4 # of Ab Doses: 1 2 3 4 18G7Ch 22.6% 8.9% 17.0% 13.8% 18G7H6A118.3% 12.6% 28.8% 28.7% 18G7H6A3 34.2% 38.1% 23.4% 28.2%

Example 10—Inhibition of Colorectal Tumor Growth In Vivo by a HumanizedAnti-LGR5 Antibody in Combination with FOLFIRI

CB.17 SCID mice were implanted with CT3 cells grown under CSCconditions. At day 40 post-implantation, when tumors reached ˜160 mm3,mice were randomized into treatment groups including i) PBS, ii) FolFiri(5FU 30 mg/kg, leucovorin 90 mg/kg and Irinotecan 24 mg/kg), given every5 days for 15 days (3 doses total), and iii) Combination of FolFiri (asin ii.) and 18G7H6A3 (15 mg/kg twice per week). Analyses of tumor volumeshowed that combination of 18G7H6A3 and FolFiri reduced growth of CT3tumors compared to FolFiri regimen. Combination treatment reduced tumorvolume at days 61, 65, 68, 71 and 75 by about 58%, 53%, 45%, 33% and 37%respectively (FIG. 2).

Example 11—Inhibition of Pancreatic Cancer Tumor Growth In Vivo by aHumanized Anti-LGR5 Antibody

To assess efficacy of 18G7H6A3 as single agent or in combination withstandard of care, a pancreatic cancer xenograft model was tested.CB17.SCID mice were implanted with AsPC-1 cells (in matrigel+RPMI in a1:1 ratio). Tumors were randomized at day 20 post implantation into 5groups: i) PBS, ii) MOPC (15 mg/kg, twice per week, ip), iii) 18G7H6A3(15 mg/kg, twice per week, ip), iv) gemcitabine (90 mg/kg, twice perweek, ip) and v) concurrent combination of gemcitabine and 18G7H6A3 atthe above doses.

It was discovered that 18G7H6A3 as single agent inhibited tumor growthcompared to saline and/or control IgG up to nearly 40% at day 41 postimplantation. In addition, the combination of 18G7H6A3 and gemcitabinesignificantly inhibited tumor growth in AsPC-1 model (up to 36% at day61 post implantation) compared to gemcitabine alone. 18G7H6A3 as singleagent also provided some inhibition in tumor growth compared to PBS andcontrol IgG up to day 65.

Example 12—Inhibition of Triple Negative Breast Cancer Tumor Growth InVivo by a Humanized Anti-LGR5 Antibody

This in vivo study was performed using low passage triple negativebreast cancer cells (ER−, PR−, no HER2 overexpression). MDA-MB-231-LM3cells were maintained in adherent culture with DMEM/10% FBS/anti-antimedium. CB.17 SCID mice were injected on day 0 with MDA-MB-231-LM3 cellsin RPMI:Matrigel (1:1) into the 4th mammary fat pad and monitored twiceweekly for tumor size and body weight. At day 27, MDA-MB-231-LM3 tumorswere randomized into 4 groups of 10 mice when tumors reached ˜155 mm³.Mice were treated with PBS, antibody control MOPC, or 18G7H6A3. Micewere dosed BIW at 15 mg/kg for 3.5 weeks (7 doses). It was discoveredthat antibody 18G7H6A3 showed significant anti-tumor activity comparedto PBS (60.7% tumor growth inhibition) or MOPC antibody (49.3% tumorgrowth inhibition) controls (FIG. 3).

Example 13—Induction of Expression of LGR5 in Colorectal Cancer CellsTreated with a SN38 or a PI3K/mTOR Inhibitor

A panel of CRC cell lines including DLD1, HCT116, LS174t, LoVo, SW48,SW480 and SW620 were treated with a PI3K/mTOR dual inhibitor (NVP) or 2different cytotoxic agents including SN38 (active metabolite ofIrinotecan) or 5FU (5 fluorouracil). Cells were treated with the aboveagents at 1 um and were harvested after 72 hrs. Cells were then stainedwith anti-LGR5 Mab conjugated to Alexa Fluor647 and the data wereanalyzed by flow cytometry using a FACScalibur.

Flow cytometry analyses of CRC cell lines showed greater expression ofLGR5 in LoVo, HCT116, LS174t, SW48, SW480 and SW620 cells when treatedwith a PI3K/mTOR inhibitor. Additionally, treatment with SN38 promotedLGR5 expression in HCT116, LS174t, SW48, SW480 and especially SW620cells. 5FU treatment, however, did not induce LGR5 expression in any ofthese lines suggesting that underlying mechanisms governing LGR5expression are distinct in these lines. These data indicate that LGR5+cells are more resistant to treatment with the above agents astreatments have mostly targeted the LGR5 negative non-cancer stem cellpopulation. To understand if treatment with these agents upregulate LGR5expression on these cells, we analyzed LGR5 cell surface expression byflow cytometry in all the cell lines. Upon treatment with PI3K/mTORinhibitor, LGR5 expression was significantly upregulated in LoVo. Thesedata indicate that treatment with small molecule inhibitors or cytotoxicagents target LGR5neg cells and causes increased expression of LGR5 inthese cells.

Example 14—LGR5 Expression is Promoted in Pancreatic Cancer Cell LinesTreated with Small Molecule Inhibitors or Cytotoxic Agents

In addition to CRC cell lines to further expand the above findings,expression of LGR5 was investigated in a series of pancreatic cell linestreated with relevant standard of care including nab-paclitaxel,gemcitabine and taxol and also small molecule inhibitors targeting mostrelevant pathways in pancreatic cancer such as inhibitors of PI3K, MEKand GSK3β. The pancreatic cell lines that were tested include: AsPc1,HPAFII, PANC1, BxPC3, CFPAC, PANC10.05, Capan2 and SW1990. Treatmentwith nab-paclitaxel results in LGR5 upregulation in PANC1, BxPc3 andPANC10.05 as assessed by flow cytometry. Gemcitabine treatmentupregulates LGR5 in PANC1 and taxol treatment results in increased LGR5expression in HPAFII. The PI3K/mTOR treatment results in upregulation ofLGR5 in CFPAC and the MEK inhibitor upregulates LGR5 in HPAFII andSW1990.

Example 15—LGR5 is Upregulated in Colorectal Cancer Tumors Treated withFOLFIRI Regimen (5FU, Leucovorin and Irinotecan)

To investigate if chemo treatment alters LGR5 expression in colorectaltumors, mice were treated every 5 days with 5FU (30 mg/kg i.p),leucovorin (90 mg/kg) and 2 different doses of irinotecan (24 mg/kg or 8mg/kg). The result of those studies showed that while CT3 tumors weresensitive to the chemo regimen, CT1 tumors did not full regress andshowed some resistance to the regimen (FIG. 4). To examine the effect ofFOLFIRI treatment of LGR5 expression, total mRNA was extracted from CT1and CT3 patient derived tumors and expression of LGR5 and was determinedby qRT-PCR and was analyzed by subtracting the Ct value (cyclethreshold) of LGR5 in each sample from its corresponding GAPDHtranscript to generate DCT (delta Ct) values. Data are presented as 2 tothe power of DCT. Analyses of abundance of LGR5 showed that the LGR5transcript is increased in both CT1 (for about 2 folds) and CT3 tumors(approximately 3.5 folds) compared to corresponding saline treatedtumors.

Example 16—LGR5 is Upregulated in Pancreatic Cancer Tumors Treated withGemcitabine Alone and in Combination of Nab-Paclitaxel

To investigate if standard of care chemotherapy treatment for pancreaticcancer alters LGR5 expression in pancreatic tumors, mice were treatedtwice per week with combination of gemcitabine and nab-paclitaxel (inJH109 primary xenografts). At terminal analysis, qRT-PCR data usingtumor cDNA showed a remarkable increase in the expression of LGR5 inchemotherapy treated tumors compared to corresponding saline-treatedtumors indicating that treatment with standard of care results inupregulation of LGR5 in tumor cells.

LGR5 expression in JH109 model which is a patient derived xenograftmodel of pancreatic tumor. Mice were implanted with tumor chunks thatwere continuously passaged in the recipient but were never exposed to invitro culture condition. Treatment of tumor-bearing mice with achemotherapy regimen (combination of gemcitabine and nab-paclitaxel)resulted in a significant inhibition in tumor growth. Consistent withthe colon cancer models, chemotherapy resulted in upregulation of LGR5(more than 4-fold) in JH109 tumors, further suggesting enrichment of thecancer stem cell population upon treatment with chemotherapy. See, forexample, FIG. 5.

Example 17—Inhibition of Pancreatic Tumor Growth In Vivo by a HumanizedAnti-LGR5 Antibody

Efficacy of 18G7H6A3 was also investigated in a pancreatic cancerxenograft model. CB.17 SCID mice were implanted with PANC1 cells(1E6/mouse s.c in matrigel+RPMI 1:1 ratio), and randomized at day 41post implantation into treatment groups: i) PBS, ii) IgG control (15mg/kg, twice per week, ip), iii) 18G7H6A3 (15 mg/kg, twice per week,ip), iv) gemcitabine (90 mg/kg, twice per week, ip) and v) concurrentcombination of gemcitabine and 18G7H6A3 (15 mg/kg, twice per week, ip).Gemcitabine was administered in assigned group for 3 weeks to inhibittumor growth. All mice were monitored twice weekly for body weight andtumor size, as well as overall health and appearance.

Analysis of tumor volume showed that while there is a trend in favor of18G7H6A3 as single agent (up to 30% at day 70 post implantation) toinhibit tumor growth, combination of 18G7H6A3 and gemcitabinesignificantly inhibited growth of PANC1 tumors (up to 52% at day 80 postimplantation) compared to gemcitabine alone group. See FIG. 6.

In this example, the significant activity of 18G7H6A3 observed whenadministered in combination with chemotherapy (gemcitabine) can beattributed to the increased expressed of the target antigen LGR5 inresponse to gemcitabine treatment.

Example 18—Inhibition of Pre-Treated Pancreatic Tumor Growth In Vivo bya Humanized Anti-LGR5 Antibody

In addition to cell lines, we also investigated the efficacy of 18G7H6A3as single agent or in combination with standard of care in the JH109primary patient derived xenograft model of pancreatic cancer. The JH109xenograft model is from a patient that had received four treatmentregimens including 5-FU, Gemcitabine, Erbitux and radiotherapy. Theoriginal patient tumor has been passaged in immune-deficient micecontinuously without any exposure to in vitro culture. To test efficacyof 18G7H6A3 in JH109 model, tumor bearing mice (n=7) were treated withcontrol IgG (15 mg/kg i.p twice/week), 18G7H6A3 (15 mg/kg i.ptwice/week) single agent, standard of care chemo (combination ofgemcitabine (50 mg/kg i.p once week; and nab-paclitaxel 30 mg/kg, i.vonce a week), combination of chemo and control IgG, and combination ofchemo and 18G7H6A3. While single 18G7H6A3 mAb did not affect tumorgrowth, combination of 18G7H6A3 with Nab-paclitaxel and gemcitabinechemotherapy led to a significantly greater degree of tumor inhibitioncompared to chemotherapy alone. 18G7H6A3 combined with chemotherapy ledto 77% greater tumor growth inhibition compared to chemotherapy alone.Three mice treated with the 18G7H7A3 chemotherapy combination hadcomplete eradication of their tumor (no measureable tumor detected). The18G7H6A3 chemotherapy combination group continued to suppress tumorgrowth even after discontinuation of treatment and one mouse was stilldevoid of any measurable tumors three months after cessation ofchemotherapy. In this example, the significant activity of 18G7H6A3observed when administered in combination with chemotherapy (gemcitabineplus nab-paclitaxel) can be attributed to the increased expressed of thetarget antigen LGR5 in response to gemcitabine nab-paclitaxel treatmentand is a demonstration of prevention of re-growth or recurrence of aprimary tumor in vivo after chemotherapy treatment to eradicate theprimary tumor bulk.

Example 19—Humanized LGR5 Antibody Treatment Reduces Cancer Stem CellPopulations

For flow cytometric analysis, cells from 5 individual tumors werestained with a variety of antibodies against stem cell specific markersCD44, and CD166. Tumors were dissociated, depleted for mouse cells andthen counted for viable cells. Dissociated cells were used for analysisof cell surface stem cell marker expression by flow cytometry.

There was a decrease in cancer stem cell population as defined byCD166+/CD44+, LGR5+/CD166+, or LGR5+/CD166+/CD44+ subpopulations (FIG.7).

Example 20—Humanized LGR5 Antibody Treatment Reduces Colon Cancer TumorRecurrence and Cancer Stem Cell Frequency In Vivo

The effects of 18G7H6A3 in combination with FolFiri were tested in coloncancer CT3 model (Example 10). The results of this primary tumorefficacy study showed that 18G7H6A3 in combination with a 3 cycleFOLFIRI regiment was more effective than FolFiri alone in reducing tumorgrowth. To determine if the 18G7H6A3 FOLFIRI combination regimen wasalso effective in reducing cancer stem cell (CSC) frequency, tumors fromday 78 were harvested, dissociated, pooled and re-implanted in alimiting dilution assay at 10, 30, 100 cells/flank into a new cohort oftumor naïve CB17.Scid mice. The mice were then monitored 2× per week fortumor growth, and tumors allowed to grow with no further treatment.

Cells isolated from mice treated with anti-LGR5 antibody 18G7H6A3 incombination with FOLFIRI had greatly decreased tumorigenicity ascompared to cells isolated from mice treated with FOLFIRI alone (FIG.8). In addition, the re-implanted cells from the 18G7H6A3 FOLFIRIcombination had a significantly slower tumor growth profile and adelayed time to progression (FIG. 9) compared to FOLFIRI alone. Finally,the 18G7H6A3 treatment reduced cancer stem cell frequency by a linearregression analysis by a factor of 6 at day 40 (1/856.3 18G7H6A3/FOLFIRIvs 1/138.6 for FOLFIRI). These data indicate that 18G7H6A3 incombination with FOLFIRI effectively targets the tumor initiating orcancer stem cell population. Day 68 was the last day for the 30cells/animal data. The data are significant at p=0.0039.

Example 21—Humanized LGR5 Antibody Treatment Reduces Pancreatic CancerTumor Recurrence and Cancer Stem Cell Frequency In Vivo

The effects of 18G7H6A3 in combination with gemcitabine were tested inpancreatic cancer PANC1 model. This study showed that 18G7H6A3 incombination with gemcitabine significantly inhibited tumor growth inPANC1 model compared to gemcitabine alone. Tumors cells from thesetreatment groups were harvested, dissociated, pooled and re-implanted ina limiting dilution assay (500, 1500, 4500 or 13500 cells/animal) into anew cohort of CB.17 SCID mice and allowed to grow with no treatment.

Cells isolated from mice treated with anti-LGR5 antibody 18G7H6A3 incombination with gemcitabine had greatly decreased tumorigenicity in thelimiting dilution assay re-implant as compared to cells isolated frommice treated with gemcitabine alone. Re-implanted PANC1 tumors treatedwith combination of gemcitabine and 18G7H6A3 showed reduction in thefrequency of engraftment in mice implanted with 4500 cells (40% ingemcitabine vs. 20% in combination) and also in mice implanted with13500 cells (100% in gemcitabine vs. 70% in combination). Using linearregression, frequency of cancer stem cell in gemcitabine implantedtumors was about 1.5 fold higher in gemcitabine compared to combinationgroup (1 in 14883 vs. 1 in 21336). These data indicate that 18G7H6A3 incombination with gemcitabine effectively targets the tumor initiating orcancer stem cell population.

In addition to PANC1 tumors, we also analyzed percentage of engraftmentand cancer stem cell frequency in an limiting dilution experiment (using500, 1500, 4500 and 13500 cells) in mice bearing AsPC-1 tumors treatedwith gemcitabine as single agent or in combination with 18G7H6A3. Tumorvolume measurement at day 40 post treatment showed a reduction inpercentage of tumor bearing mice in gemcitabine vs. combination in miceimplanted with 4500 or 13500 cells (40% and 80% vs. 30% and 50%,respectively). Frequency of cancer stem cells was also greater by morethan 1.5 fold in gemcitabine vs. combination group further indicatingthat 18G7H6A3 in combination with gemcitabine is targeting cancer stemcell population in pancreatic cancer.

Example 22—Humanized LGR5 Antibody Treatment Reduces Triple NegativeBreast Cancer Tumor Recurrence and Cancer Stem Cell Frequency In Vivo

The effects of 18G7H6A3 in combination with paclitaxel were tested inthe triple negative breast cancer MDA-MB-231-LM3 model (Example 12).This study showed that 18G7H6A3 in combination with paclitaxel hadminimal additive inhibition in tumor growth compared to paclitaxelalone. These tumors were harvested, dissociated, pooled and re-implantedin a limiting dilution assay at 10, 30, 100 cells/flank into a newcohort of CB.17 SCID mice and allowed to grow with no treatment.

Cells isolated from mice treated with anti-LGR5 antibody 18G7H6A3 incombination with paclitaxel had greatly decreased tumorigenicity ascompared to cells isolated from mice treated with paclitaxel alone. Inaddition, the re-implanted cells from the 18G7H6A3 plus paclitaxeltumors had a significantly slower tumor growth profile and a delayedtime to progress compared to paclitaxel alone. Finally, the 18G7H6A3plus paclitaxel treatment reduced cancer stem cell frequency by a linearregression analysis. These data indicate that 18G7H6A3 in combinationwith paclitaxel effectively targets the tumor initiating or cancer stemcell population.

Example 23—Inhibition of Metastatic Colorectal Cancer Growth In Vivo byProphylactic Treatment with Humanized Anti-LGR5 Antibody andChemotherapy

The in vivo study was performed using low passage colorectal cancercells (BMCRC086) derived from a liver met of a patient with colorectalcancer. On Day 0, BMCRC086 cells were thawed, suspended in RPMI:Matrigel(1:1) and injected subcutaneously into the rear flank of CB.17 SCIDmice. Animals were monitored twice weekly for tumor size and bodyweight. At day 7, mice were treated with PBS, 18G7H6A3, FOLFIRI orFOLFIRI in combination with 18G7H6A3. Mice were dosed with PBS and18G7H6A3, BIW at 15 mg/kg for 7.5 weeks (16 doses). Mice were dosed withFOLFIRI (30 mg/kg Fluorouracil and 90 mg/kg Leucovorin on days 7, 12,17, 22, 27 and 32; 24 mg/kg Irinotecan on days 8, 13, 18, 23, 28 and 33)for 4 weeks (6 doses). 18G7H6A3 in combination with FOLFIRI showedsignificant anti-tumor activity compared to FOLFIRI alone (FIG. 10).

Example 24—Humanized LGR5 Antibody Treatment Inhibits Wnt SignalingPathways

18G7H6A3 treated tumors from colon cancer CT1 (Example 8) and CT3(Example 9) in vivo tumor efficacy studies were characterized by westernblot analysis. Tumor samples from each treated mouse (n=5 to 10 mice pergroup) were resected after sacrificing, immediately frozen in a liquidnitrogen cooled mortar, ground-up pestle (cryopulverization), flashfrozen in liquid nitrogen and stored at −80° C. until used.Cryopulverized tumors were lysed with ice cold lysis buffer (reducingRIPA buffer containing phosphatase and protease inhibitors) for 30minutes on ice with occasional vortexing. Supernatants containing tumorlysate protein were run on a SDS-PAGE gel followed by western blottingfor a number of Wnt-signal proteins (and their phosphorylated forms). Anumber of significant differences between treatment groups were observedin western blots of CT1 and CT3 tumors. In FIG. 11,phospho-Thr41/Ser45-β-catenin (a Wnt-signal protein) is a marker ofinactive, and subsequently degraded, form of the protein demonstrating18G7H6A3 is able to inhibit LGR5 signaling in tumor cells in vivo.

Example 25—Humanized LGR5 Antibody Treatment Does Not Inhibit In VitroWnt-Signaling Pathway

Parental HEK-293T cells and HEK-293T cell stably expressing LGR5 weretransduced with a TCF-LEF reporter vector-containing lentivirus (GFPCignal, QIAGEN) and selected for stable expression of the reporter.Parental and LGR5 expressing stable reporter lines were plated at25,000/well in a 96 well plate, attached overnight, serum starved andtreated with antibodies or vehicle for 6 h, then treated withrecombinant human Wnt3a (3 nM) and recombinant human R-spondins for 18h. Two concentrations for each R-spondins1-3 and one concentration ofR-spo4 were tested (100 pM, 300 pM, 1 nM, 3 nM or 10 nM) based on ouranalysis of the activity of the different R-spondins in activation ofthe TCF/LEF reporter cell lines. The reporter driven GFP signal wasmeasured on a plate reader. All experiments shown are pooled data fromthree independent experiments (each experiment performed in duplicate)for each R-spondin tested (data are means+SD).

As shown in FIG. 12, increasing concentrations of soluble 18G7H6A3 didnot affect the induction of TCF/LEF promoter driven GFP expression bythe combination of Wnt3a plus RSPO1, RSPO2 or RSPO3. A positive controlantibody 76C12, which has been shown to inhibit the induction ofsignaling activity through both LGR4 and LGR5 in the presence of RSPOand Wnt, is also shown. This data demonstrates that the anti-LGR5antibody 18G7H6A3 does not block RSPO-driven TCF/LEF promoteractivation.

Example 26—Humanized LGR5 Antibody Targets Tumor Cells Via ADCC(Antibody Dependent Cell Cytotoxicity) Mechanism

CHO-LGR5 cells were grown to confluent and were spun down, resuspendedin PBS and were counted. An aliquot of cells (approximately 100 k) wereadded to another tube containing 100 μM pre-warmed (37° C.) CFSE(Carboxyfluorescein succinimidyl ester) and the mixture was incubated inthe cell incubator for 15 min. The final CFSE concentration was about 1μM. Next, cells were washed and resuspended in pre-warmed medium andwere placed in the incubator for another 30 minutes followed by washingwith PBS. The stained cells were then stained with 18G7H6A3 (100 μM). Toensure binding of the antibody to CHO-LGR5 cells, in some studies analiquot of cells was also stained with a secondary goat anti-human PEconjugated antibody and was analyzed on the calibur machine in thelaboratory. The U937 cells were stained with DDAO-SE (DDAO succinimidylester; 2 μM of dye for 100K cells) for 15 minutes and in a lightprotected place in the laboratory and at room temperature. Cells werethen 1 ml of FBS (fetal bovine serum) followed by incubation in a lightprotected place for 5 minutes. Next, cells were washed with PBSsupplemented with FBS (10%) and were resuspended in RPMI supplementedwith FBS (2.5%). Both CHO-LGR5-18G7H6A3 and U937-DDAO-SE labeled cellswere co-incubated in the cell incubator for 5 hrs and were analyzed inthe calibur machine in the laboratory. As a negative control, an aliquotof CHO-LGR5-CFSE cells (no 18G7H6A3 staining) was also co-incubated withU937 and was analyzed on the calibur machine.

Analysis of flow cytometry data showed that majority of CHO-LGR5 cellsstained with CFSE and 18G7H6A3 are viable and detectable in the caliburmachine. Additionally, both U937 (U937 (human monocyte cell line;effector cells) and CHO-LGR5 cells were detectable when stained and wereacquired individually. Finally co-incubation of U937-DDAO-SE andCHO-LGR5-CFSE-18G7H6A3 identified a double positive population of cells,however, co-incubation of U937 and CHO-LGR5-CFSE which lacks 18G7H6A3did not generate the double positive population. The presence of thedouble positive population is indicative of a cross binding of U937(which express FcR) to CHO-LGR5-18G7H6A3 (which express Fc portion) andfurther suggests that ADCC is one of the mechanisms of anti-tumoractivity of 18G7H6A3.

Example 27—Humanized LGR5 Antibody Internalizes LGR5

Internalization of 18G7H6A3 was examined on CHO cell overexpressingLGR5. Cells were stained with 100 nM antibody for 30 min-2 hrs at 4° C.,excess Ab was washed off and stained cells were incubated at either 4°C. or 37° C. Cells were stained with AlexaFluor488-conjugated secondaryantibodies at various time points to monitor internalization of cellsurface-bound antibodies. Upon incubation at 37° C., the internalizedrate had a measured t½ value for surface localization of 6.703±1.282minutes. Internalization was largely blocked by incubation at 4° C.although some decrease in surface-bound antibody was observed.

Example 28—Humanized LGR5 Antibody Does Not Competitively Block Bindingof Soluble RSPOs to LGR5

Interaction of biotin-18G7H6A3 with hLGR5-Fc in the presence of humanR-spondin 1/2/3/4 proteins was examined using competition ELISA format.LGR5-Fc was coated on a 96-well high binding ELISA plate at 2 μg/mL, andincubated overnight at 4 C. The plate was blocked with PBS+1% BSA.Biotin-18G7H6A3 was diluted in binding buffer to 1 μg/mL. Theconcentration was chosen from previous direct binding ELISA betweenLGR5-Fc and biotin-18G7H6A3 to give robust signal above EC50concentration. Competitor proteins were added to the ELISA plate at thesame time as biotin-18G7H6A3 at varying concentrations. A dilution of1:1,000 of streptavidin-HRP (R&D Systems, cat #890803) was used fordetection. Plate was developed with TMB (Thermo), and data werecollected on SpectraMax Plus 384 plate reader at 450 nm. Data analysiswas done using GraphPad Prism 6 program. The ELISA was repeated threetimes with some modifications of biotin-mAb and competitorconcentrations.

As a positive control, LGR5-Fc was competed with the binding ofbiotin-18G7H6A3 to hLGR5-Fc on the plate. R-spondins 1/2/3/4 were testedfor the ability to block binding of biotin-18G7H6A3 to LGR5-Fc coated onthe plate. The proteins were purchased from R&D Systems, and are fulllength constructs expressed in mammalian cells. At the highestconcentration of R-spondin proteins, complete blocking of antibodybinding to LGR5 was not observed (FIG. 13).

Example 29—Humanized LGR5 Antibody Does Not Competitively Block Bindingof Soluble RSPOs to LGR5

Binding of ligand alone (RSPO or Norrin) to LGR5 is not sufficient toinduce LGR5 signaling. Instead, LGR5 forms ternary complexes withmultiple co-receptors to drive signaling. To examine the effects of18G7H6A3 on the formation of LGR5 ternary complexes, the binding of LGR5to RNF43, ZNRF3, and LRP6 in the presence of R-spondin 1/2/3/4 andNorrin was examined using an ELISA format. RNF43-Fc, ZNRF3-Fc, andLRP6-Fc were coated on a 96-well high binding plate at 4 μg/mL in 1×PBS.The plate was incubated overnight at 4° C. and blocked with PBS+1% BSA.LGR5-Fc was diluted in primary buffer to 1 μg/mL, all in the presence orabsence of 1 μg/mL of R-spondin 1/2/3/4 or 0.5 μg/mL of Norrin.R-spondin 1/2/3/4 or Norrin were preincubated together with hLGR5-Fcbefore being added to the ELISA plate. Triplicate wells were used foreach condition was tested in triplicate. 1:2,000 anti-FLAG mAb (CellSignaling) was used to detect bound hLGR5-Fc. 1:10,000 dilution ofanti-mouse IgG HRP (JIR) was used for detection. Plate was developedwith TMB (Thermo), and data were collected on SpectraMax Plus 384 platereader at 450 nm. Data analysis was done using GraphPad Prism 6 program.Formation of a ternary complex with LGR5, ligands RSPO or Norrin, andco-receptor (RNF43-Fc, ZNRF3-Fc, and LRP6-Fc) was observed.

Next, 18G7H6A3 was added in addition to the ELISA plate in the presenceof LGR5-Fc and RSPO or Norrin. 18G7H6A3 significantly reduced theformation of LGR5 ternary complexes with both RSPO and Norrin ligands aswell as all three co-receptors (RNF43, ZNRF3, and LRP6). See FIG. 14. As18G7H6A3 does not directly or competitively compete with ligand binding,this data is evidence of an allosteric model of inhibition.

Example 30—Epitope Mapping of Anti-LGR5 Antibody 18G7H6A3

To further characterize the specific region(s) of LGR5 that antibody18G7H6A3 binds, an epitope mapping experiment was performed usinghydrogen deuterium exchange mass spectrometry. Prior to conducting thehydrogen-deuterium exchange experiments, test digests prepared withundeuterated buffer in varying concentrations of guanidine hydrochloride(GdnHCl) were made to optimize proteolysis conditions for the bestpeptide coverage of LGR5 alone. For pepsin digestion for DXMS, a samplewas thawed at 5° C. and then immediately digested over a protease columnfilled with porcine pepsin (Sigma) at a flow rate of 100 μl/min with0.05% trifluoroacetic acid. Peptic fragments were collected on a C18trap column and separated on a C18 reversed phase column (Vydac) with alinear acetonitrile gradient from 6 to 38%. The column effluent waselectrosprayed directly into an LCQ Classic (Thermo Finnigan, Inc.) orQ-TOF mass spectrometer (Micromass). Determination of pepsin-generatedpeptides from MS/MS data sets was facilitated through the use of SEQUEST(Thermo Finnigan, Inc.). This set of peptides was then further verifiedby DXMS Explorer (Sierra Analytics Inc., Modesto, Calif.). The peptidecoverage maps for the different concentrations of GdnHCl were compared,and the condition with the best coverage map for each individual proteinor protein complex was used for subsequent deuterium exchangeexperiments. All steps were performed at 0° C. as described previously.

Exchange experiments were initiated by mixing LGR5-Fc in protein buffer,or LGR5-Fc preincubated with 18G7H6A3 with D20 buffer to a finalconcentration of 50% D20. The mixtures were incubated at 0° C. for 10,30, 100, 300, 1,000, 3,000, or 10,000 s and then the exchange reactionwas quenched by adding ice-cold quench solution (0.96% formic acid,0˜0.8 M guanidine hydrochloride) resulting in samples with finalconcentrations of 0.58% formic acid and 0˜0.5 M guanidine hydrochloride,pH 2.5. The samples were then immediately frozen on dry ice and storedat −80° C. Data processing of DXMS experiments utilized specializedsoftware as previously described (DXMS Explorer, Sierra Analytics Inc.).

The hydrogen/deuterium (H/D)-exchange data provide details regardingchanges in solvent exposure due to binding of 18G7H6A3 and the buryingof surface exposed residues upon binding of antibody to antigen. The HDexchange data analysis indicates that 18G7H6A3 binds to amino acidsT175, E176, Q180, R183, 5186, A187, Q189, D247, E248, T251, R254, 5257,N258, K260 of SEQ ID NO: 47 within the convex surface of leucine richrepeats 6-9, on the opposite of the face of the R-spondin binding siteas identified by X-ray crystallographic studies. (See e.g., Chen et al.Genes Dev. 27(12):1345-50 which is incorporated by reference in itsentirety). These data show that the residues involved in binding of LGR5to the R-spondins are not involved in binding 18G7H6A3. Thesepreliminary results do not preclude that fact that other structuralelements in LGR5 may be involved in the binding site of 18G7H6A3.

Example 31—Administration of 18G7H6A3 to a Human Patient Suffering fromColon Cancer

A population of human patients suffering from colon cancer is treatedwith chemotherapy and tumor volume is monitored. It is observed thataverage tumor volume ceases to expand and in fact decreases uponinitiation of chemotherapy. Following an extended duration of time, thetumor volume stabilizes and eventually begins to increase.

A second human patient population suffering from colon cancer is treatedwith chemotherapy co-administered with 18G7H6A3. Again, average tumorvolume is monitored. It is observed that tumor volume ceases to expandand in fact decreases upon initiation of chemotherapy. It is observedthat tumor volume decreases to a minimum volume that is substantiallylower than that of the first population. It is also found that tumorsize remains low for a substantially extended period of time relative tothe first population.

Example 32—Administration of 18G7H6A3 to a Human Patient Suffering fromColon Cancer

A first population of human patients suffering from colon cancer isadministered chemotherapy alone. A second population of human patientssuffering from colon cancer is administered chemotherapy in combinationwith 18G7H6A3.

The first population demonstrates a temporary reduction in tumor sizeand growth, after which tumor growth resumes and symptoms return. Tumorgrowth after chemotherapy treatment is recalcitrant to subsequentchemotherapy treatments.

The second population demonstrates reduction in tumor size to a basallevel and cessation of tumor growth. Tumor growth does not resume duringor upon completion of a treatment regimen. After completion of theregimen, growth does not return and symptoms of the cancer are no longerpresent in the second population.

Example 33—Administration of 18G7H6A3 to a Human Patient Suffering fromColon Cancer Increases Survival

A first population of human patients suffering from colon cancer isadministered chemotherapy alone. A second population of human patientssuffering from colon cancer is administered chemotherapy in combinationwith 18G7H6A3.

Patient survival at a set duration after treatment (1 year) ismonitored. It is observed that patient survival in the second populationis substantially higher than patient survival in the first population.That is, a significantly higher proportion of the second populationsurvives past the first year after treatment as compared to the survivalrate of the first population.

Similar observations are made at later intervals, and it is observedthat among survivors at the first interval, members of the second groupare significantly more likely to survive to a second interval (2 yearsafter treatment) that are members of the first group alive at 1 yearpost treatment.

Example 34—Administration of 18G7H6A3 to a Human Patient Suffering fromBreast Cancer

A population of human patients suffering from breast cancer is treatedwith chemotherapy and tumor volume is monitored. It is observed thataverage tumor volume ceases to expand and in fact decreases uponinitiation of chemotherapy. Following an extended duration of time, thetumor volume stabilizes and eventually begins to increase.

A second human patient population suffering from breast cancer istreated with chemotherapy co-administered with 18G7H6A3. Again, averagetumor volume is monitored. It is observed that tumor volume ceases toexpand and in fact decreases upon initiation of chemotherapy. It isobserved that tumor volume decreases to a minimum volume that issubstantially lower than that of the first population. It is also foundthat tumor size remains low for a substantially extended period of timerelative to the first population.

Example 35—Administration of 18G7H6A3 to a Human Patient Suffering fromBreast Cancer

A first population of human patients suffering from breast cancer isadministered chemotherapy alone. A second population of human patientssuffering from breast cancer is administered chemotherapy in combinationwith 18G7H6A3.

The first population demonstrates a temporary reduction in tumor sizeand growth, after which tumor growth resumes and symptoms return. Tumorgrowth after chemotherapy treatment is recalcitrant to subsequentchemotherapy treatments.

The second population demonstrates reduction in tumor size to a basallevel and cessation of tumor growth. Tumor growth does not resume duringor upon completion of a treatment regimen. After completion of theregimen, growth does not return and symptoms of the cancer are no longerpresent in the second population.

Example 36—Administration of 18G7H6A3 to a Human Patient Suffering fromBreast Cancer Increases Survival

A first population of human patients suffering from breast cancer isadministered chemotherapy alone. A second population of human patientssuffering from breast cancer is administered chemotherapy in combinationwith 18G7H6A3.

Patient survival at a set duration after treatment (1 year) ismonitored. It is observed that patient survival in the second populationis substantially higher than patient survival in the first population.That is, a significantly higher proportion of the second populationsurvives past the first year after treatment as compared to the survivalrate of the first population.

Similar observations are made at later intervals, and it is observedthat among survivors at the first interval, members of the second groupare significantly more likely to survive to a second interval (2 yearsafter treatment) that are members of the first group alive at 1 year pottreatment.

Example 37—Administration of 18G7H6A3 to a Human Patient Suffering fromColon Cancer Decreases Side Effects

A first population of human patients suffering from colon cancer isadministered chemotherapy and an anti-LGR5 antibody that blocksLGR5-RSPO binding and signaling. A second population of human patientssuffering from colon cancer is administered chemotherapy and 18G7H6A3.

The first population demonstrates non-therapeutic side effectsassociated with the interference of RSPO1 signaling through LGR5. Theseside-effects are detrimental to patient health.

The second population, administered 18G7H6A3 in combination withchemotherapy, does not demonstrate non-therapeutic side effectsassociated with the interference of RSPO1 signaling through LGR5.

Example 38—LGR5 Expression in Advanced CRC Tumors

LGR5 transcript expression was investigated using RNAscope technologywith LGR5 specific probes. LGR5 transcript was detectable in tissuesincluding colon, intestine, cerebellum and pancreas. LGR5 transcript wasalso detectable in patient derived xenograft (PDX) tissues including CT1CRC and JH109 pancreatic tumors. LGR5 expression was investigated in CRCpatient samples isolated at different stages of tumorigenesis includingearly (Grade-I) vs. advanced (Metastatic) lesions. LGR5 transcript wasexpressed in CRC Grade I, II and II lesions, and was highly expressed inCRC metastatic lesions.

Example 39—LGR5 Expression in Metastatic Pancreatic Patient DerivedXenografts

LGR5 expression in metastatic pancreatic patient derived xenografts wasinvestigated using the quantitative polymerase chain reaction (QPCR). Asample of tumor tissue was flash frozen or added to a cryovialcontaining RNAlater (Qiagen, CA), and transferred to −70° C. afterincubation at 4° C. for several hours. Total RNA was extracted using aQiagen RNeasy extraction kit (Qiagen, CA), and cDNA was synthesizedusing a SuperScriptIII kit (Life Technologies, CA) and protocolsprovided by the manufacturer. Human LGR5 transcript abundance wasmeasured using human specific LGR5 and GAPDH primers and the followingthermal condition in the StepOne Thermocycler (Life Technologies, CA):50° C. (2 min); 90° C. (2 min) and 40 cycles of 90° C. (15 sec) and 60°C. (1 min) and melt curve assessment (from 65° C.-95° C.). LGR5abundance was quantified using 2{circumflex over ( )}δCt equation.

LGR5 was highly expressed in metastatic pancreatic patient derivedxenografts. Treatment with chemotherapy resulted in increased LGR5expression in pancreatic tumors. Using human specific primers, LGR5transcript was measurable using QPCR in a series of pancreatic patientderived xenografts. While LGR5 was detectable in most tumors there was atrend for increased LGR5 expression in metastatic tumors furthersuggesting a role for LGR5 in advanced tumorigenesis.

LGR5 expression was investigated in a series of pancreatic tumorsincluding JH109, ASPC1 and PANC1. Treatment with a standard of caretreatment (SOC) (Gemzar and Abraxane in JH109 and Gemzar alone in PANC1and ASPC1) resulted in an induction in LGR5 expression in each of theforegoing tumors (FIG. 15). Notably, LGR5 expression was reduced tolevels comparable to controls (saline or MOPC) in tumors treated withcombination of 18G7H6A3 and SOC. These data further indicate that LGR5expression can serve as a biomarker of response to combination therapy(18G7H6A3+SOC) in PANC tumors.

Example 40—CTNNB1 is One of the 18G7H6A3 Target Genes in CRC andPancreatic Tumors

Potential targets in the Wnt pathway for 18G7H6A3 were investigated. WntQPCR plates (Qiagen, CA) were prepared with primers for about 80 Wntpathway genes in a 96 well PCR plate. cDNA from 18G7H6A3 or MOPC(control) treated tumors was pooled and QPCR in the Wnt plate wasperformed. Data in each plate was normalized to corresponding GAPDH andthe abundance of each gene was measured using an 2{circumflex over( )}δCt equation. To measure fold differences, data in each 18G7H6A3treated tumor was divided by the corresponding value from MOPC treatedgroup. Values above 1 or below 1 were indicative of upregulation ordownregulation in 18G7H6A3 treated group, respectively. Preliminaryassessment of the number of genes that were up- or down-regulated showedthat in both tumor models (CT1 and CT3) there were more downregulatedgenes than upregulated genes, suggesting 18G7H6A3 has an inhibitoryeffect on gene expression. Detailed analyses identified severaldifferentially expressed genes including FZDB, FZD7, WNT7B, FBW11, FZD1,DVL1, CSNK2A1 and CTNNB1.

In cervical cancer, there may be a close correlation between LGR5expression and CTNNB1. In other studies, over-expression (using LGR5recombinant vector) or dowregulation of LGR5 (using shRNA) resulted inupregulation or downregulation of CTNNB1, respectively (Chen Q, Cao HZ,Zheng PS. 2014. Oncotarget 5: 9092-105). Additionally, analysis ofimmunohistochemical slides from cervical cancer patients showed asignificant correlation between LGR5 and CTNNB1 expression. In thisstudy, CTNNB1 expression was investigated further using QPCR (to measuretranscript level) and Western Blotting (to assess protein expression).Using human specific primers, CTNNB1 expression was investigated inpancreatic and CRC tumors. Similar to LGR5 expression explained inExample 45, treatment with SOC increased CTNNB1 expression and thecombination of 18G7H6A3 and SOC resulted in a reduction in CTNNB1expression. Additionally, CTNNB1 expression was reduced about 35% in CT1tumors treated with 18G7H6A3. Thus, treatment with 18G7H6A3 inhibitsCTNNB1. Expression of β-catenin and phospho-β-catenin (indicative oflack of activity in Wnt pathway) was investigated by western blotanalysis. Western blot data in ASPC1 tumors confirmed QPCR data in which18G7H6A3 as single agent or in combination with SOC upregulatedpβ-catenin suggesting inhibition of Wnt pathway activity in these tumors(FIG. 16).

Other components of the Wnt pathway including p-β-catenin, GSK-3β (totaland phospho), and LRP6 were investigated in a series of CRC, pancreaticand breast tumors. Quantification of Western blot data showedsignificant inhibition of Wnt pathway signaling in ASPC1 and PANC1tumors but also revealed some trends in favor of Wnt pathwaydownregulation in other models. BMCRC086 tumors that were not responsiveto treatment with 18G7H6A3 were also negative for the expression of LGR5and Wnt signaling pathway components, further supporting that themechanism of action for 18G7H6A3 was specifically targeting LGR5 andinhibiting Wnt signaling.

Expression of Wnt pathway genes in pancreatic tumors including ASPC1,PANC1 and JH109 was investigated. Based on in vivo data, in both PANC1and ASPC1 there was a difference in tumor volume between 18G7H6A3- vs.PBS-treated tumors. In contrast, JH109 tumors did not respond to astandard treatment regimen with either 18G7H6A3 single agent or SOCchemo combination. Differences in Wnt gene expression in responsivecells (PANC1 and ASPC1) and non-responsive cells (JH109) wereinvestigated. In combo treated groups, Wnt6, FZD8, FOSL1, Wnt11, NFATCand FZD5 were downregulated in both ASPC1 and PANC1 combo-treatedtumors, are were upregulated in JH109 tumors. In both the pancreatic andCRC data, genes including WNT11, WNT6, FRZB and PRICKEL weredownregulated in PANC1, ASPC1, CT1 and CT3 cells, but not in JH109cells.

Gene Tree analysis identified potential genes co-regulated in pancreatictumors treated with 18G7H6A3 that included Wnt11, FRAT1, LEF1, GSK3B,FZD8 and LRP6. Analysis of differentially expressed transcripts in eachtreatment also identified genes that were up/down regulated more than 2fold in pancreatic tumors (FIG. 17). Some genes, such as Wnt7A, werecommon between all the tumors in 18G7H6A3 vs. control treated tumors.

Example 41—18G7H6A3 Inhibits Transcription in CT1 Tumors

Expression of 18G7H6A3-targeted genes were investigated in early vs.late tumorigenesis. Mice were implanted mice with CT1, and tumors wereharvested from control, 18G7H6A3, FOLFIRI or combo groups at days 3, 10and 17. Total RNA from each tumor at day-3 was harvested and preparedfor gene array hybridization using Illumina human chips. Overallanalysis of differentially expressed genes (more than 1.5 or 2 folds,p<0.05) showed that in tumors treated with 18G7H6A3 (as single agent orin combination with FOLFIRI) there are more downregulated genes thanupregulated ones. This suggested that treatment with 18G7H6A3 may havehad a more suppressive impact on overall cellular transcriptionalmachinery. PCA (Principal Component Analyses) also showed a proximity inoverall gene expression in 18G7H6A3 and control treated tumors. However,when 18G7H6A3 was added to FOLFIRI (i.e. combo group) there was clearseparation between combo vs. FOLFIRI suggesting that targeting LGR5 mayhave significantly changed gene expression in FOLFIRI-treated tumors.

Analysis of differentially expressed genes in 18G7H6A3 vs. Vehicleidentified several tumor promoters such as ANGPT2, AKAP12 and ADM thatwere downregulated in 18G7H6A3 treated tumors, and also several tumorsuppressors such as DAB1, MIR655, NKX1-2 that were upregulated in18G7H6A3 treated tumors (FIG. 18). Conversely FOLFIRI treatment appearsto upregulate tumor promoters (FBN2, HKDC1, ABCB1, FGF2) and also sometumor suppressors such as TRIB3, ATF3 and TIMP3 (FIG. 19). Combinationof FOLFIRI and 18G7H6A3 resulted in downregulation of more tumorpromoters such as ALDOC, CDH5, ITGA2 and also upregulation of more tumorsuppressors such as ZBTB11, ITPKA, PSMC3IP and BAK1 (FIG. 20).

Example 42—18G7H6A3 Treatment Significantly Reduces Human CTCs inPeripheral Blood in Orthotopic Models of Pancreatic Patient DerivedXenografts

To investigate the role of 18G7H6A3 in inhibition of primary tumorgrowth and metastasis, LGR5 expression was examined in a series ofpancreatic patient derived xenograft samples, and PANC1424 cells andPANC1427 cells.

Tumor samples were subcutaneously implanted in NOD/SCID (non-obesediabetic severe combined immunodeficient) mice and subsequentlyimplanted into the pancreas in recipients designated for in vivostudies. Tumor volume was measured weekly in ultrasound and mice withtumors ˜100 mm³ were enrolled into the efficacy study and were treatedwith the followings: 1—MOPC isotype (15 mg/kg twice/week; ip);2—18G7H6A3 (15 mg/kg twice/week; ip); 3—SOC (Gemzar 50 mg/kg; ip twiceper week and Abraxane 30 mg/kg iv twice per week); 4—Combination of18G7H6A3 and SOC at the above doses. At the end of the study, peripheralblood from each tumor bearing mouse was collected for CTC (using flowcytometry) and circulating DNA assessments. For flow cytometry, bloodsamples were treated with RBC lysis buffer (ACK buffer, Life Tech, CA)using manufacturer protocol and were stained with human HLA-FITC(eBiosciences, CA) and human LGR5-AF647 (BD Pharmingen, CA) for 30 minat 4° C. Cells were washed with staining buffer (PBS-FBS 3%) twice and7AAD (7-aminoactinomycin) prior to acquisition in the FACS caliburmachine in the laboratory and the data were analyzed using FCS Expresssoftware (De Novo, Calif.).

LGR5 was expressed in various pancreatic patient derived xenograftsamples. Human CTCs were detected in the peripheral blood. Whilepercentage of HLA+ cells did not significantly change in MOPC vs.18G7H6A3, the percentage of circulating HLA+LGR5+ cells wassignificantly reduced in 18G7H6A3 treated mice (FIG. 21).

The percentage of HLA+ cells did not significantly change in chemo vs.combo treated mice, however, combination of 18G7H6A3 and SOC almostcompletely ablated HLA+LGR5+ cells in both concurrent and debulksettings (FIG. 22A, and FIG. 22B). 18G7H6A3 treatment (as single agentor in combination with SOC) significantly reduces human CTCs inperipheral blood in orthotopic models of pancreatic patient derivesxenografts.

Example 43—LGR5 Expression in Other Models

LGR5 expression was investigated in skin samples from Cynomolgusmacaques (Cynos) using flow cytometry and RNAscope. Skin samples fromCynos were treated with vehicle or various doses of 18G7H6A3 (G2:10mg/kg; G3:50 mg/kg; and G4: 150 mg/kg) at day 0, 7, 14 and 21. At studytermination, skin samples were provided in DMEM supplemented withantibiotic (penicillin and streptomycin) and antimycotic solution(Anti-Anti 100×, Life Technologies, CA). Skin samples were digestedusing a cocktail of collagenases and thermolysin (Liberase, Roch Inc,CA). Skin progenitors (SPs) were isolated after overnight incubationwith Liberase and mechanical disruption. SPs were stained with Ratanti-human LGR5 (AF647, BD Pharmingen, CA) and were analyzed in acalibur machine in the laboratory. Data analyses using FCS Express(Denovo Software, CA) showed that LGR5 was detectable in Cynos SPs,however, there was no significant difference in LGR5 frequency between18G7H6A3 (at different doses) vs. vehicle treated group. Using RNAscope,LGR5 was detectable in skin areas especially in hair follicles and to amuch lesser extent in skin epithelial cells. There was no significantdifference in LGR5 positive area in vehicle vs. 18G7H6A3 treatedsamples.

Gene expression peripheral blood monocytes isolated from the Cynos wasinvestigated. Total RNA was extracted using Qiagen RNeasy kit and cDNAwas synthesized using Superscript cDNA Synthesis Kit (Life Technologies,CA). The cDNA from each treatment was pooled and was added to RT²Sybergreen qPCR master mix (SABiosciences, MA). The final mixture wasadded to each well of a 96-well plate containing Cyno QPCR primers forchemokines or inflammatory cytokines. PCR thermal profile included: 95°C. for 10 min and 40 cycles of 95° C. 15 sec and 60° C. 1 min followedby melt curve stage. Data (Ct values) in each plate was normalized bysubtracting from the corresponding GAPDH and the abundance of eachtranscript was calculated using 2{circumflex over ( )}DCT equation.Analyses of the number of transcripts differentially expressed (morethan 2 folds) between any of the 18G7H6A3 group vs. vehicle treatedgroup showed that, consistent with gene array data, there are much moredownregulated genes than the upregulated ones. With dose escalationthere were less upregulated genes and more downregulated genes. TheG4-recovery (G4R) group in which Cynos did not receive any treatment for4 weeks after the last dose of 18G7H6A3 showed almost similar number ofup-down-regulated genes. Detailed analysis identified differentiallyexpressed genes (CCL11, IL3, SPP1, CCL13, CXCL6 and TNFRSF11b) whoseexpression was inversely correlated with 18G7H6A3 dose i.e. highest in10 mg/kg and lowest in 150 mg/kg.

Genes that were commonly downregulated between the treatments includedCCL1, IFNγ, CCR8, IL2, IL3 and IL4, some of which are enriched in M1 orM2 macrophages.

Example 44—Inhibition of Small Cell Lung Cancer Tumor Growth In Vivo bya Humanized Anti-LGR5 Antibody

Patient derived small cell lung cancer xenograft model. Dissociatedtumor cells from BLG293 tumors were implanted into CB.17 SCID mice inMatrigel subcutaneously, and monitored twice weekly for tumor size andbody weight. When tumors reached an average of 130 mm3, mice wererandomized. Mice were treated with either PBS, antibody control MOPC, or18G7H6A3. Mice were dosed BIW at 15 mg/kg for. All mice were monitoredtwice weekly for body weight and tumor size, as well as overall healthand appearance, until termination.

18G7H6A3 showed significant anti-tumor activity compared to PBS (24.9%tumor growth inhibition) and MOPC antibody (24.7% tumor growthinhibition) controls.

Example 45—18G7H6A3 Increases Survival in Mice with Pancreatic Tumorsthat Relapse Following Debulk Chemotherapy Therapy

Panc1427 (UCSD1427) tumors were completely debulked (regressed) bytreatment with chemotherapy (Gemcitabine/Abraxane) and 18G7H6A3. Whentumors were regressed, chemotherapy was removed and mice were treatedwith either 18G7H6A3 or no treatment. Animals treated with 18G7H6A3 werenoticeably more healthy compared to the control animals, where severalmice had to be euthanized due to severe health observations such aslameness or body weight loss. At day 150, 7/8 mice treated with 18G7H6A3and chemotherapy were alive, versus 4/8 mice treated with chemotherapyalone. FIG. 23 summarizes the results.

Example 46—Administration of 18G7H6A3 to Patients

A Phase I, Dose Escalation Study of BNC101 (anti-LGR5 humanizedmonoclonal antibody) in patients with metastatic colorectal cancer isperformed as described below. Name of Finished Product: BNC101 Solutionfor Infusion. Name of Active Ingredient: BNC101, 18G7H6A3, ET101, LGR5Antibody.

Study Objectives

To determine the maximum tolerated dose (MTD), recommended Phase II dose(RP2D), safety, tolerability and pharmacokinetic (PK) profile of BNC101administered intravenously to patients with metastatic colorectalcancer. The primary objective is to determine the MTD of BNC101, both assingle agent and in combination chemotherapy in metastatic colorectalcancer patients. The secondary objectives are as follows. To determinethe RP2D of BNC101, both as single agent and in combination chemotherapyin metastatic colorectal cancer patients. To evaluate the safety andtolerability of BNC101 [adverse events (AEs), dose omissions or delays].To assess for immunogenicity of BNC101 (production of antibodies againstBNC101). To determine the pharmacokinetics (PK) of BNC101 (half-life,volume of distribution and clearance), both as single agent and incombination with chemotherapy. To make a preliminary assessment of theOverall Response Rate (ORR), Progression-Free Survival (PFS) and OverallSurvival (OS) of metastatic colorectal cancer patients treated withBNC101. Exploratory objectives are as follows. To assess changes indisease-related biomarkers (CEA). To evaluate biomarkers of activity[pharmacodynamics, e.g. circulating tumor cells (CTCs), LGR5+ cells,circulating tumor DNA].

Safety Endpoints

To assess treatment-emergent events (clinical and laboratory data). Toevaluate dose interruptions and discontinuations.

Key Patient Selection Criteria

1. Signed written Informed Consent. 2. Age >18 years. 3. EasternCooperative Oncology Group (ECOG) performance status score of 0-1. 4.Histologically or cytologically confirmed colorectal cancer patients whohave failed at least 2 lines of chemotherapy (monotherapy treatmentcohorts) or at least 1 line of chemotherapy (combination treatmentcohorts) for metastatic disease, and in the opinion of both physicianand patient it is not unreasonable to try experimental therapy. AdjuvantFOLFOX (Folinic acid; Fluorouracil (5-FU); and Oxaliplatin) within thelast 6 months is considered a line of therapy. A maintenance strategypost 1st line treatment is not considered as an additional line oftherapy. 5. Patients must have accessible tumor lesions amenable tobiopsy which would not put the patient or their treatment at risk.Patients in monotherapy escalation cohort 3 and onwards, the monotherapyexpansion cohort, and all combination treatment patients, agree and arewilling to provide 2 serial tumor lesion biopsies (a minimum of 2 freshcores/punches preferred whenever possible). Biopsies can be from livermetastases, in lieu of the primary tumor. The presence of tumor tissuein fresh biopsies is to be certified by a trained pathologist usingappropriate extemporaneous histology or cytology procedures. 6.Measurable disease per Response Evaluation Criteria in Solid Tumors(RECIST) version 1.1. 7. No known brain metastases. 8. Life expectancyof at least ≥12 weeks. 9. Normal organ and marrow function: a. Absoluteneutrophil count >1,500/mL without growth factor support in the past 14days prior to enrollment. b. Platelets >100,000/mL without transfusionsin the past 14 days prior to enrollment. c. Hemoglobin ≥9.0g/dL—Patients may be transfused or receive erythropoietic treatment tomeet this criterion. d. Total bilirubin <1.5× institutional upper limitof normal (ULN) (<2×ULN for subjects with Gilbert's syndrome). e. SerumAlbumin ≥3 g/dL. 10. Aspartate aminotransferase (AST) (serum glutamicoxaloacetic transaminase, SGOT) and alanine aminotransferase (ALT)(serum glutamic pyruvate transaminase, SGPT)<2.5× institutional ULN (forsubjects with hepatic involvement <5× institutional ULN but cannot beassociated with elevated bilirubin). 11. For patients receivingbiopsies, prothrombin time (PT) and activated partial thromboplastintime (APTT)/international normalized ratio (INR) within normal limits(±15%). 12. Creatinine <1.5× institutional ULN OR Creatinineclearance >60 mL/min/1.73 m2 for subjects with creatinine levels aboveinstitutional normal. 13. Adequate contraception in women and men offertile potential.

Dosing and Schedule

Escalation will take place in two separate sets of cohorts, in astaggered fashion: single agent BNC101 dose escalation will precede doseescalation in the combination chemotherapy cohorts. In the latter,BNC101 will be dose-escalated in combination with FOLFIRI. Combinationchemotherapy cohorts will not commence treatment until the RP2D has beendetermined in the monotherapy cohorts. Escalation in the combinationchemotherapy cohorts will commence one level below the single agent RP2Dof the monotherapy cohorts. Although no additive toxicities are expectedfrom combining BNC101 with chemotherapy, two additional de-escalationlevels below the initial dose will be available, should they berequired.

BNC101 Monotherapy

The standard 3+3 Phase I study design will be used. The starting dosewill be 1/30th of the highest no-observed-adverse-event-level (NOAEL)dose in animals (2.5 mg/kg in humans), which has been calculated takinginto account species differences in receptor binding. Subsequent BNC101dose levels will be 5, 10, and 15 mg/kg.

The schedule of administration will be weekly (q1w).

Cycle duration will be 4 weeks (28 days) (4 weekly infusions), with noweek of rest between cycles.

Dose escalation will be conducted to determine the MTD. No doseescalation or reduction will be allowed within a dose cohort. In allinstances, BNC101 should be administered in the morning, to enabletimely preparation and shipment of blood samples for translationalresearch on the same day.

Dose escalation will begin with a cohort of 3 patients at a dose of 2.5mg/kg ( 1/30th of the highest NOAEL dose in animals). If, at the end of28 days (4 administrations of BNC101), no CTCAE grade ≥2 AEsattributable to the study drug are observed, a second cohort of 3patients will be treated at the next dose level (5 mg/kg). Further doseescalations will continue in cohorts of 3 patients (starting at 10 mg/kgand then 15 mg/kg).

If 1 of 3 subjects in a 3-subject cohort experiences a dose-limitingtoxicity (DLT), that dose level will be expanded to 6 subjects. If 2 ormore subjects experience a DLT, no further subjects will be dosed atthat level and 3 additional subjects will be added to the preceding dosecohort unless 6 subjects have already been treated at that dose level.

Subjects will be assessed for DLTs from the time of the first dosethrough 28 days. Dose escalation for newly enrolled subjects, ifappropriate, will occur after all subjects in a cohort have completedtheir Day 28 DLT assessment. Subjects with stable disease or a responseat or after Day 56 (2 cycles) will be allowed to continue to receiveweekly doses of BNC101 until disease progression.

If no DLTs are reported at the highest BNC101 dose tested, the cohort ofpatients demonstrating a PK profile with BNC101 exposure comparable tothe maximum exposure demonstrated in laboratory animals (cynomolgusmonkeys) will be the RP2D.

A minimum of 9 additional subjects will be further enrolled at thehighest dose level that results in <2 of the 6 subjects experiencing aGrade 3 (not including a Grade 3 infusion reaction that resolves in 24hours) or Grade 4 AE (DLT), or after adequate PK exposure has beenachieved, in the absence of such toxicities.

BNC101 in Combination with FOLFIRI

After BNC101 monotherapy dose escalation is completed, declared safe andthe RP2D reached, the metastatic colorectal cancer patients can bestarted on their combination chemotherapy cohorts with BNC101 at 1 doselevel below the RP2D identified in monotherapy. These cohorts willcontain 3 subjects each. Escalation will proceed as per the same rulesused with monotherapy cohorts. Should this initial BNC101 dose show DLTsin 2 of a maximum of 6 patients, 2 additional de-escalation cohorts willbe provided, following the 3+3 rules, to identify the RP2D incombination chemotherapy.

If no DLTs are reported at the highest BNC101 dose combination tested,the cohort of patients demonstrating a PK profile with BNC101 exposurecomparable to the maximum exposure demonstrated in laboratory animalswill be the RP2D in combination with chemotherapy.

A minimum of 9 additional subjects will be further enrolled in thecombination cohorts at the highest dose level that results in <2 of the6 subjects experiencing a Grade 3 (not including a Grade 3 infusionreaction that resolves in 24 hours) or Grade 4 AE (DLT) or afteradequate PK exposure has been achieved, in the absence of suchtoxicities.

FOLFIRI components: Irinotecan (IRI)—Starting dose 180 mg/m² (over 90minutes on Day 1) Leucovorin (LV)—Starting dose 400 mg/m² (administeredover 120 minutes on Day 1 concurrently with IRI) 5-FU bolus—Startingdose 400 mg/m² (administered after LV on Day 1, then) 5-FUinfusion—Starting dose 2400 mg/m² (administered over 48 hours startingon Day 1). FOLFIRI Cycles are repeated every 14 days.

DLT Definition

A DLT is defined as any of the following occurring in Cycle 1 (Days0-28) of any given escalation cohort: Grade 3 or 4 non-hematologicaltoxicity (including anaphylactic reactions) using the NCI CTCAE v4.0;Grade 3 nausea of more than 48 hours duration or Grade 4 vomiting orGrade ≥3 diarrhea, either occurring despite appropriate treatment; Grade4 thrombocytopenia of any duration and Grade 4 uncomplicated neutropenia(i.e., without fever or infection) of any duration in the monotherapycohorts or lasting >7 days in the combination chemotherapy cohorts.Grade 4 febrile neutropenia requiring hospitalization and any Grade 3hematologic toxicity requiring treatment delay beyond 3 weeks andprolongation of QTc interval to ≥500 msec or a 60 msec increase frombaseline mean QTc interval. Any other drug-related ≥ Grade 3non-hematologic adverse event (including anaphylactic reactions), excepthyperlipidemia in subjects not receiving maximum medical management orelectrolyte abnormalities that may be managed with supplements. All AEswill be considered as potentially related to treatment unless there is aclear-cut relationship between the observed toxicity to diseaseprogression (PD). Adverse events meeting these criteria will not beconsidered for the purposes of reporting DLTs or in determining the MTD.

Length of Treatment

Patients will be treated until PD, intolerable toxicity, withdrawal ofconsent, or study termination by the sponsor, whichever occurs first.

Sample Size

Up to approximately 54 patients will be treated in this study todetermine the toxicity profile, DLTs, and MTD and/or RP2D of BNC101,both in monotherapy and in combination chemotherapy. It is anticipatedthat 1 to 6 evaluable patients per dose level cohort will providesufficient data to assess the toxicity and PK profile of BNC101. Oncethe RP2D is identified, expansion of these cohorts (to at least 9additional patients) will occur in both the monotherapy and combinationchemotherapy groups. If no DLTs are reported at the highest BNC101 dosetested, the cohort of patients demonstrating a PK profile with BNC101exposure comparable to the maximum exposure demonstrated in laboratoryanimals will be the RP2D.

Frequency of Visits

Every 7 (±3) days for each week of the 4-week cycle. Survival follow-upinformation and subsequent anti-cancer therapies will be collected every3 months after cessation of treatment, until death, loss to follow-up,patient withdrawal of consent, or study termination by the sponsor.

Safety Assessments

Subjects will be assessed for DLT from Days 0-28 (Cycle 1). Adverseevents will be reported through 30 days after the last dose. Safety willbe reported continuously. Adverse events occurring between Day 28 and 30days after the last dose will be reported, but will not be integral tothe determination of the MTD. Performance status will be scored weekly,and physical examination will be conducted at baseline, at the beginningof each cycle (e.g., every 4 weeks), at the end-of-study (EOS) visit andat the time of resolution of any AEs.

Electrocardiogram (ECG) Monitoring

All 12-lead ECGs are to be obtained in triplicate and at least 5 minutesapart. ECGs will be obtained at baseline (in the 14 days previous tofirst dosing), on Cycle 1 Day 1 and Day 15 intensively and at pre-doseon Days 8 and 22. ECGs will be obtained pre-dose on Day 1 of Cycle 2 andsubsequent cycles. An EOS ECG must be collected. ECGs will be forwardedto a local laboratory for assessment.

Response Assessments

Computed tomography (CT) scans will be performed at baseline and every 8weeks. First response assessment will be at Day 56 (after 2 cycles).Radiologic studies for antitumor response will be repeated at the EOSvisit if not done within the previous 28 days. Phone follow-up or reviewof records will be done on a monthly basis for 6 months and every 3months thereafter for 18 months (total of 24 months).

Pharmacokinetic Assessment

Pharmacokinetic samples will be obtained intensively on Cycle 1, Days 1and 15, and sparsely on Days 8 and 22. Samples will be obtained sparselyon Day 1 of Cycle 2 and subsequent cycles. Blood samples will be takenpre-dose (before the infusion is started), during the infusion, andpost-infusion (after the end of the infusion) of BNC101.

Cellular and Molecular Biomarkers Assessment

Patients will have blood taken at baseline, weekly during Cycle 1, Day 1of each subsequent cycle and at the end of treatment, to measure levelsof CTCs and biomarkers (including, but not limited to LGR5) as anindicator of pharmacodynamic effect. Patients will also have 2 matchedskin biopsies at baseline and Cycle 1, Day 22 (each biopsy will be 2fresh core/punches). Patients may have additional hair samples(including collection of the hair follicle) taken.

Tumor Lesion Biopsies

No biopsies are required for monotherapy escalation cohorts 1 and 2.Matched biopsies (baseline and Day 22) are mandatory for monotherapyescalation cohort 3 and onwards, and the monotherapy expansion cohort.Matched biopsies will be mandatory for all combination treatmentpatients. Each biopsy will be a minimum of 2 fresh cores/punchespreferred whenever possible. Biopsies can be from liver metastases, inlieu of the primary tumor. The presence of tumor tissue in freshbiopsies is to be certified by a trained pathologist using appropriateextemporaneous histology or cytology procedures. All samples will bede-identified. The identity of the individual may not be ascertained bythe investigators or the sponsor. Password-protected data residing inthe central reference laboratory will not be released to patients orphysicians treating the patients. Patient information will be usedstrictly in anonymous reporting of research data. Such research datawill not be placed in patient charts or made available to clinicians andwill not and cannot be used for diagnostic or treatment purposes.

Immunogenicity Assessments

The presence of anti-BNC101 antibodies will be tested at baseline, priorto each dose, at treatment termination, and every 4 weeks afterdiscontinuation of treatment for 12 weeks. Due to the different natureand expected evolution of patients in the monotherapy vs. thecombination therapy cohorts, different number of samples may beobtainable in each.

The term “comprising” as used herein is synonymous with “including,”“containing,” or “characterized by,” and is inclusive or open-ended anddoes not exclude additional, unrecited elements or method steps.

The above description discloses several methods and materials of thepresent invention. This invention is susceptible to modifications in themethods and materials, as well as alterations in the fabrication methodsand equipment. Such modifications will become apparent to those skilledin the art from a consideration of this disclosure or practice of theinvention disclosed herein. Consequently, it is not intended that thisinvention be limited to the specific embodiments disclosed herein, butthat it cover all modifications and alternatives coming within the truescope and spirit of the invention.

All references cited herein, including but not limited to published andunpublished applications, patents, and literature references, areincorporated herein by reference in their entirety and are hereby made apart of this specification. To the extent publications and patents orpatent applications incorporated by reference contradict the disclosurecontained in the specification, the specification is intended tosupersede and/or take precedence over any such contradictory material.

What is claimed is:
 1. A method of treating a subject having a cancercomprising administering an effective amount of a humanized monoclonalantibody or an antigen-binding fragment thereof that specifically bindsleucine-rich repeat-containing G-protein coupled receptor 5 (LGR5) incombination with a chemotherapeutic agent to the subject in needthereof, wherein: the monoclonal antibody comprises a heavy chaincomprising SEQ ID NO:13 and a light chain comprising SEQ ID NO:14; themonoclonal antibody is administered weekly for at least 4 weeks; themonoclonal antibody is administered intravenously; the dosage of themonoclonal antibody is between about 2.5 mg/kg to about 15 mg/kg; and aninitial dose of the monoclonal antibody is administered prior toadministration of the chemotherapeutic agent.
 2. The method of claim 1,wherein the chemotherapeutic agent is selected from the group consistingof folinic acid, fluorouracil, irinotecan, gemcitabine and nanoparticlealbuming bound paclitaxel.
 3. The method of claim 2, wherein themonoclonal antibody is administered in combination with folinic acid,fluorouracil, and irinotecan.
 4. The method of claim 2, wherein aninitial dose of the monoclonal antibody is administered prior toadministration of folinic acid, fluorouracil, and irinotecan.
 5. Themethod of claim 2, wherein an initial dose of irinotecan is about 180mg/m² administered over about 90 minutes.
 6. The method of claim 5,wherein an initial dose of folinic acid is about 400 mg/m² administeredover about 120 minutes and concurrently with the initial dose of theirinotecan.
 7. The method of claim 6, wherein an initial dose offluorouracil is about 400 mg/m² administered after administration of theinitial dose of the folinic acid.
 8. The method of claim 7, wherein theagents are folinic acid, fluorouracil, and irinotecan and which areadministered every 14 days.
 9. The method of claim 1, wherein themonoclonal antibody is administered in combination with an additionaltherapeutic agent selected from the group consisting of bevacizumab,aflibercept, cetuximab, and panitumumab.
 10. The method of claim 1,wherein the cancer comprises a solid tumor.
 11. The method of claim 1,wherein the cancer is selected from the group consisting of coloncancer, colorectal cancer, pancreatic cancer, breast cancer, and lungcancer.
 12. The method of claim 1, wherein the cancer is selected fromthe group consisting of colon cancer comprising an APC mutation, coloncancer comprising an KRAS mutation, metastatic colorectal cancer,metastatic pancreatic cancer, triple-negative breast cancer, and smallcell lung cancer.
 13. The method of claim 1, wherein the cancer is ametastatic colorectal cancer.
 14. The method of claim 1, wherein thesubject has a characteristic selected from the group consisting of:failed at least 1 line of prior chemotherapy for metastatic diseaseprior to administration of the monoclonal antibody; has no known brainmetastases; has a life expectancy of 12 weeks or more; has an absoluteneutrophil count greater than about 1500 cells/mL without growth factorsupport in the 14 days prior to administration of the monoclonalantibody; has a platelet count greater than 100,000 platelets/mL withouttransfusions in the 14 days prior to administration of the monoclonalantibody; has a hemoglobin greater than or equal to 9.0 g/dL; and hasserum albumin greater than or equal to 3 g/dL.
 15. The method of claim1, wherein the subject is mammalian.
 16. The method of claim 1, whereinthe subject is human.